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37th PARLIAMENT, 2nd SESSION

Standing Committee on Health

EVIDENCE

CONTENTS

Monday, October 27, 2003

0905

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

Dr. Allan Abbass (Director of Education, Department of Psychiatry, Centre for Emotions and Health, Dalhousie University)

Mr. Svend Robinson (Burnaby—Douglas, NDP)

Dr. Allan Abbass

0910

0915

The Chair

Ms. Margaret Dykeman (Associate Professor and Nurse Manager, Community Health Clinic, University of New Brunswick, Faculty of Nursing)

0920

0925

The Chair

Ms. Margaret Dykeman

The Chair

Dr. David Zitner (Director, Medical Informatics, Faculty of Medicine, Dalhousie University)

0930

Dr. David Zitner

0935

The Chair

Mr. Rob Merrifield (Yellowhead, Canadian Alliance)

Dr. Allan Abbass

Mr. Rob Merrifield

Dr. Allan Abbass

Mr. Rob Merrifield

Dr. Allan Abbass

Mr. Rob Merrifield

Dr. Allan Abbass

Mr. Rob Merrifield

Dr. Allan Abbass

0940

Mr. Rob Merrifield

Dr. Allan Abbass

Mr. Rob Merrifield

Dr. Allan Abbass

Mr. Rob Merrifield

Dr. Allan Abbass

Mr. Rob Merrifield

Dr. Allan Abbass

Mr. Rob Merrifield

Dr. Allan Abbass

Mr. Rob Merrifield

Dr. Allan Abbass

Mr. Rob Merrifield

Dr. Allan Abbass

Mr. Rob Merrifield

Ms. Margaret Dykeman

0945

Mr. Rob Merrifield

Ms. Margaret Dykeman

Mr. Rob Merrifield

Dr. David Zitner

Mr. Rob Merrifield

Dr. David Zitner

The Chair

Mr. Réal Ménard (Hochelaga—Maisonneuve, BQ)

0950

Dr. Allan Abbass

Mr. Réal Ménard

Dr. Allan Abbass

0955

Mr. Réal Ménard

Dr. David Zitner

The Chair

Ms. Carolyn Bennett (St. Paul's, Lib.)

1000

Dr. Allan Abbass

Ms. Carolyn Bennett

Dr. Allan Abbass

Ms. Carolyn Bennett

Dr. Allan Abbass

Ms. Carolyn Bennett

Dr. Allan Abbass

Ms. Carolyn Bennett

Dr. Allan Abbass

Ms. Carolyn Bennett

Dr. Allan Abbass

Ms. Carolyn Bennett

Dr. Allan Abbass

Ms. Carolyn Bennett

Dr. Allan Abbass

Ms. Carolyn Bennett

Dr. Allan Abbass

Ms. Carolyn Bennett

Dr. Allan Abbass

Ms. Carolyn Bennett

Ms. Margaret Dykeman

1005

Ms. Carolyn Bennett

Ms. Margaret Dykeman

Ms. Carolyn Bennett

Ms. Margaret Dykeman

Ms. Carolyn Bennett

Dr. David Zitner

Dr. Allan Abbass

Ms. Carolyn Bennett

Dr. David Zitner

The Chair

Mr. Svend Robinson

1010

Dr. Allan Abbass

Mr. Svend Robinson

Dr. Allan Abbass

Mr. Svend Robinson

Dr. Allan Abbass

Mr. Svend Robinson

Dr. David Zitner

1015

Mr. Svend Robinson

The Chair

Mr. Gilbert Barrette (Témiscamingue, Lib.)

Ms. Margaret Dykeman

Mr. Gilbert Barrette

Ms. Margaret Dykeman

Mr. Gilbert Barrette

Dr. David Zitner

1020

The Chair

Mr. Gilbert Barrette

The Chair

The Vice-Chair (Mr. Réal Ménard)

Mr. Don McIver (Director of Research, Atlantic Institute for Market Studies)

1030

The Vice-Chair (Mr. Réal Ménard)

Mr. Peter Hogan (President, New Brunswick Pharmacists' Association)

1035

The Vice-Chair (Mr. Réal Ménard)

Mr. Rob Merrifield

1040

Mr. Peter Hogan

Mr. Rob Merrifield

Mr. Peter Hogan

Mr. Rob Merrifield

Mr. Peter Hogan

Mr. Rob Merrifield

Mr. Peter Hogan

Mr. Rob Merrifield

Mr. Peter Hogan

Mr. Rob Merrifield

1045

Mr. Peter Hogan

Mr. Rob Merrifield

Mr. Peter Hogan

Mr. Rob Merrifield

Mr. Peter Hogan

Mr. Rob Merrifield

Mr. Peter Hogan

Mr. Rob Merrifield

Mr. Peter Hogan

Mr. Rob Merrifield

Mr. Don McIver

1050

Mr. Rob Merrifield

Mr. Don McIver

Mr. Rob Merrifield

Mr. Don McIver

The Vice-Chair (Mr. Réal Ménard)

Mr. Svend Robinson

Mr. Don McIver

Mr. Svend Robinson

Mr. Don McIver

Mr. Svend Robinson

Mr. Don McIver

Mr. Svend Robinson

Mr. Don McIver

Mr. Svend Robinson

Mr. Don McIver

Mr. Svend Robinson

Mr. Don McIver

Mr. Svend Robinson

Mr. Don McIver

Mr. Svend Robinson

Mr. Don McIver

Mr. Svend Robinson

Mr. Don McIver

Mr. Svend Robinson

Mr. Don McIver

Mr. Svend Robinson

1055

Mr. Don McIver

Mr. Svend Robinson

Mr. Don McIver

Mr. Svend Robinson

Mr. Don McIver

Mr. Svend Robinson

Mr. Don McIver

Mr. Svend Robinson

Mr. Don McIver

Mr. Svend Robinson

Mr. Peter Hogan

Mr. Svend Robinson

Mr. Peter Hogan

1100

The Vice-Chair (Mr. Réal Ménard)

Mr. Gilbert Barrette

Mr. Peter Hogan

Mr. Gilbert Barrette

Mr. Peter Hogan

Mr. Gilbert Barrette

Mr. Peter Hogan

Mr. Gilbert Barrette

Mr. Peter Hogan

1105

Mr. Gilbert Barrette

Mr. Don McIver

The Vice-Chair (Mr. Réal Ménard)

Ms. Carolyn Bennett

Mr. Peter Hogan

Ms. Carolyn Bennett

Mr. Peter Hogan

Ms. Carolyn Bennett

1110

Mr. Peter Hogan

Ms. Carolyn Bennett

Mr. Peter Hogan

The Vice-Chair (Mr. Réal Ménard)

Ms. Carolyn Bennett

Mr. Peter Hogan

The Vice-Chair (Mr. Réal Ménard)

The Chair

Ms. Maureen Summers (Executive Director, Canadian Cancer Society - Nova Scotia Division)

Ms. Carolyn Bennett

Ms. Maureen Summers

1130

The Chair

Mr. Ian Johnson (Vice-Chairperson, Nova Scotia Citizens Health Care Network)

1135

Ms. Peggy Brown (Disabled Individuals Alliance Representative, Nova Scotia Citizens Health Care Network)

The Chair

Ms. Sheila Richardson (Valley Chapter, Council of Canadians, and Member of Health Network, Nova Scotia Citizens Health Care Network)

1140

The Chair

Ms. Mary Boyd (Chair, P.E.I. Health Coalition; Director, MacKillop Centre for Social Justice)

1145

1150

The Chair

Ms. Mary Boyd

The Chair

Ms. Carol Tooton (Executive Director, Nova Scotia Division, Canadian Mental Health Association)

The Chair

1155

Ms. Claudette Gaudet (Consumer, Canadian Mental Health Association)

The Chair

Mr. Rob Merrifield

Ms. Claudette Gaudet

Mr. Rob Merrifield

Mr. Ian Johnson

Ms. Carol Tooton

Mr. Rob Merrifield

The Chair

1200

Mr. Réal Ménard

Mr. Ian Johnson

Mr. Réal Ménard

The Chair

Ms. Carol Tooton

The Chair

Ms. Maureen Summers

1205

The Chair

Ms. Peggy Brown

The Chair

Ms. Mary Boyd

Mr. Réal Ménard

The Chair

Ms. Carolyn Bennett

Ms. Maureen Summers

1210

Ms. Carolyn Bennett

Ms. Maureen Summers

Ms. Carolyn Bennett

Ms. Carol Tooton

The Chair

Ms. Carolyn Bennett

Ms. Claudette Gaudet

Ms. Carolyn Bennett

Ms. Claudette Gaudet

Ms. Carolyn Bennett

Ms. Claudette Gaudet

1215

Ms. Carolyn Bennett

Ms. Claudette Gaudet

The Chair

Mr. Svend Robinson

1220

Ms. Peggy Brown

Mr. Svend Robinson

Ms. Maureen Summers

Mr. Svend Robinson

Mr. Ian Johnson

Mr. Svend Robinson

The Chair

Mr. Gilbert Barrette

1225

Mr. Ian Johnson

The Chair

Ms. Maureen Summers

The Chair

Ms. Mary Boyd

1230

The Chair

CANADA

Standing Committee on Health

NUMBER 062

2nd SESSION

37th PARLIAMENT

EVIDENCE

Monday, October 27, 2003

[Recorded by Electronic Apparatus]

¿ (0905)

[English]

The Chair (Ms. Bonnie Brown (Oakville, Lib.)): Good morning, ladies and gentlemen.

We're so happy to be here in beautiful downtown Halifax, which is so much more beautiful than I remember it from about ten years ago. People have been out walking, exploring the old town, and it's really most impressive.

This morning, ladies and gentlemen, for our study of prescription drugs, we have three witnesses. First, from the Centre for Emotions and Health at Dalhousie University, we have Dr. Allan Abbass, the director of education in the Department of Psychiatry.

Dr. Abbass, the floor is yours.

Dr. Allan Abbass (Director of Education, Department of Psychiatry, Centre for Emotions and Health, Dalhousie University): Thank you.

Welcome, everyone. Bonjour.

Emotion-based difficulties are extremely common, costly, and generally not well managed. These problems include anxiety, depression, substance abuse, personality problems, and a range of physical problems, including irritable bowel syndrome, certain types of headache problems, fibromyalgia, chest pain, and a whole range of other common complaints, including other health problems like hypertension and asthma. All of these conditions are well established as linked with emotions and how a person deals with them.

Most family physicians and specialist consultations are for no discernible physical problem, meaning that most of the money going to those is for assessing the body when the problem is as much linked with emotions as the physical effects themselves. Hospital costs, waiting lists, emergency visits, injury, violence, and disabilities are also driven by emotional factors.

Our conclusion, based on research, is that emotion-based disturbances are probably the number one social and health-related cost in our Canadian system.

All of these problems are treatable with emotionally focused and brief psychotherapies that look at this emotion processing problem. These treat a full range of non-psychotic symptom disturbances, including personality disorders, and they result in cost savings in the system, in terms of medical costs and social system costs, in the range of about $3 a day for every $1 spent on these treatments.

Some studies, including my own, show that with these treatments over 80% of people are able to stop their medications, and over 80% of people are able to return to work off disabilities. They also result in fewer hospital dates and lower physician costs. Basically, patients at the end of treatment are the same as normal on every measure we've used.

I have a few slides on the next page of the handout, showing the medication reduction with treatment, total number of medications used, medication costs after treatment, and the unemployment rate.

The patient rate before treatment in this study is one-quarter—

Mr. Svend Robinson (Burnaby—Douglas, NDP): Sorry, but I don't see the slides.... Oh, here they are.

Dr. Allan Abbass: On the second page I have a few graph illustrations of medication costs before and after treatment.

This is one study of EI patients treated in B.C. The patient unemployment rate was 25% before treatment, and after treatment it was 4.9%, outperforming the Vancouver city norm. So patients looked normal after this treatment, which focuses on emotion and how a person deals with it. Disability costs went from almost $600,000 down to $150,000 one year after.

The bottom illustration just shows physician and hospital costs, the differences after the patients received treatment. The dotted curve is the continuation of what the cost for the patient should have been if they had continued in the same trend. The solid curve is what they actually did. The difference between these two curves paid for my salary as a psychiatrist to provide this treatment. Also, this just shows that the cost savings continue for three years afterwards, so it's a continuation.

Why I am bringing this whole issue up is that most of the patients we see come on anti-depressant medications and other medications. If you compare any studies that compare this type of treatment to anti-depressants, what you see is that overall in the short run these medications are as effective as the psychotherapies; they're equally effective. However, these psychotherapies treat tougher patients, including patients with personality disorders. Personality disorders are not treated with medication. Patients prefer this type of treatment over medications when they've had options, and there's research to show that.

There are lower relapse rates when you use the psychotherapy compared to higher relapse rates with anti-depressants. These don't have a physical toxicity because there's no chemical involved and usually people stop chemical medications during treatment. And anti-depressants have toxicity, as we know, as a chemical.

There are no physical side effects with psychotherapy and there is usually some degree of side effect with anti-depressant medications. There is less drop-out with the psychotherapy and there's more drop-out with medication treatment. Psychotherapy is easy to stop; there is sometimes some psychological withdrawal effect, but there is no physical withdrawal. On the other hand, medications, often the new ones, are very hard to stop. And the cost is less over time for psychotherapy compared to medications.

Overall functioning improves with psychotherapy, as is demonstrated on some of these slides, and this is a question mark with anti-depressant medication. We don't know what the overall effect on function is, and it's a real question mark in the literature.

Given that, then it would make sense that there's liberal access and people are well aware of the benefits of these types of treatments. One could ask why that's not the case, and certainly it is not the case.

If you read any medical journal you'll see pages upon pages of advertisement. Turn on the TV, and anywhere you look there's massive marketing backed by billions of dollars in direct-to-public as well as direct-to-physician advertisement, singing the virtues of pharmaco-therapy.

As well as direct-to-physician marketing, there are benefits to physicians. There are multiple presentations by industry, so a lot of education is backed by industry. University departments are dependent on industry funding; and major agencies, including medical associations, are often dependent on industry funding for their education.

¿ (0910)

There are a lot of awards for research and funding for research in the medication area. So they have the budget. They have the power in that sense to market, and that's what businesses do, and it's quite appropriate. These medications are lifesavers and so helpful for some patients. But by the same token, in my experience, most patients don't need them, and there's a downside and patients don't prefer them.

So basically what we're looking at then is a major marketing deficit. There's an imbalance in what is taught, what is provided, what is funded, because people, including administrators, don't know about these things and they keep hearing about the virtues of medication. So this is where we're at.

Based on that, in my brief I arrived at some thoughts on potential recommendations, one of which is to review the magnitude of this problem in Canada somehow and to look and see if it matches other research in the literature. There's ample research around the costs of these emotion-based problems. There's also research on everything I've said; I can provide papers and data for all of it. I can put it all together if that's of interest to people. There are reviews and such on it.

In summary, I have some points. One is to provide public education about risks and benefits of medications versus brief therapies for anxiety, depression, somatic problems, and other conditions in a balanced way. So we need balance in public education. Any direct-to-patient marketing in Canada must include a clear statement of risks of medications and benefits of brief psychotherapies. What about some compulsion that they report on what else are alternatives to medication? These are the kinds of things that would make sense.

Education must be allotted equal time with medication advertising. Education in psychotherapy must be allowed equal time with medication advertising, in the same way as smoking has mandatory reporting of risks and alternatives. We can do it the same way. Universities and other educational institutions must ensure balance of education, recognizing the emotional component of physical and mental health problems on par with biological sciences. So we need research and education that balances.

Clear boundaries between the pharmaceutical industry and educational institutions must exist to prevent bias in education and research funding. So we need to try to even up the research in these areas and the education. And boundaries between physicians and industry must be ensured so that there's not on one level or other some kind of benefit coming back to physicians for prescribing.

Physicians need ongoing marketing about the downside of medication and upside of brief psychotherapies to balance off what they already get, which is a massive upside of medications and then nothing else. This is something that may need a bit of an overshoot in order to get to a balance. Since they save money in the medical system, brief therapy should be liberally provided to the public and funding given to therapies that have the same indication.

Thank you.

¿ (0915)

The Chair: Thank you, Mr. Abbass.

Next, we'll hear from the University of New Brunswick Faculty of Nursing, Margaret Dykeman, associate professor and nurse manager.

Ms. Margaret Dykeman (Associate Professor and Nurse Manager, Community Health Clinic, University of New Brunswick, Faculty of Nursing): Good morning, and thank you.

I think Allan has given half of my brief, because my points are very much along the same kinds of lines as his.

The community health clinic was opened in Fredericton in 2002 by the faculty of nursing to look after or provide better access to people living on the street, the low-income people in the city and the addicted population. What has come out of this is the fact that we have a very large addicted population in and around the city—which can also be extrapolated to the whole province, because addiction in the province is growing by leaps and bounds on probably a daily basis, I would expect.

This has opened a whole new can of worms, because a lot of this addiction is coming from persons taking care of chronic pain. About one-third of our clients have actually been addicted through the use of narcotics to control their pain. This translates into a whole societal problem, because when family members start using narcotics, the whole family starts using narcotics. We have families with mothers, fathers, sons, daughters, and uncles who are trying to get into the methadone program because you can't get one person off of a substance without getting the family off it. It's a family-oriented problem.

So all of this is the background.

When you're looking at addiction from the perspective of chronic pain, you have to look at the current practices for prescribing, what the treatment modalities are, and the research, or the lack thereof, addressing the issue of pain control. In Canada, at the federal level we have been going toward harm reduction modalities that will help alleviate some of the complications of trying to go the more stringent route of your either using or not using drugs, which hasn't worked very well in the past for us—and I suspect nowhere in the world. It has also cost us an enormous amount of funds, because some of our clients—not so much our methadone clients—are in and out of the addiction services. Some of them have been there a hundred times, and they still don't have any success levels you could talk about.

So all of this was the basis for the faculty getting into the business, so to speak.

In New Brunswick, the drug of choice for the majority of addicts is Dilaudid, which is good, on one hand, because it doesn't carry all of the nasty connotations of having to mix heroin and cut it with very nasty things. On the other hand, when you are an addict, no matter what you're using for drugs, it is your whole life and whole lifestyle.

All of the 40 clients we have who got into this business because of chronic pain have gone to the street for their drugs, because the medical society just cannot, after a while, support the need of the underlying addiction to control both the addiction and the pain. So they have to take what they can get from their doctors, and then they have to go to find the rest of it illegally. So what happens is that we have rapidly growing addiction, without any constraint in most cases.

One of the offshoots of all of this is the cost to society. We have addicts who are using up to $1,000 of drugs a day, which is costing society huge amounts of money for policing, incarceration, and all of the medical problems that go along with addiction.

Because of the process of looking for drugs, we're finding that our clients do not have access to the treatment services for other illnesses. Some of our clients are coming in with multiple, multiple, multiple diagnoses. So we have people with six or eight diagnoses who haven't been looked after, many on the psychiatric...which is what sends them out looking for drugs in the first place.

¿ (0920)

We don't only have physical pain, we have a lot of psychiatric pain in this world. So in order to fix your pain, you go looking for what helps. A lot of people these days are choosing to medicate, though our hope is they would choose something else.

Some of the basis for all of this has been that there are a lot of unhealthy behaviours on the street. We have arrived to full HIV and hepatitis C. In the nine months we've been open, we've diagnosed 12 new hepatitis C cases, one of them last week that was in the acute stage.

The offshoot of this is that all of these people, no matter whether you got addicted because you had chronic pain, which makes you a good addict in society, or whether you got addicted because your father molested you at the age of eight, which makes you a bad addict in society, all of these people are in trouble. They're all addicts, and society then stigmatizes them as addicts--maybe a little less if you're a chronic pain user, but you're stigmatized.

This means that you don't get a lot of the services. The services you do get have a tendency to have restraints on them, because this was your problem, you chose to do this. I would challenge anyone around this table to say that once a person is addicted to any substance, they have any choices. When you become addicted, you give away your choices.

We need a lot more education for persons caring for people who are addicted, no matter what the source of their addiction. We need research to look at some of the modalities for care. We need research to look into how we can deal with chronic pain without using only narcotics, how we can deal with psychiatric problems without using only pills.

We have very little research that tells us what you can do for chronic pain around the other modalities, massage therapy, acupuncture, those kinds of things. When we get some research that looks at these things, we need to include them in the care plan and in the service we provide through our health care system. I ran a clinic that's run on a whole different modality for offering services; therefore I can offer massage therapy, because I have eight students who come in once a week and give it to my clients free. But I cannot buy it for them, because I don't have the funding. So we need to look at those kinds of things.

If we can put multiple dollars into buying pills every day, we should as a country be able to put multiple dollars into the adjunct therapies that may offer even better outcomes than the pills do.

In addition, we need some kind of a tracking system, because it is human nature for people to try to solve their problems the easiest way they know how, and doctor shopping is a big problem. If you can buy pills from three doctors in three different cities, you will do that, because it's legal. It may not be legal in our minds, but it's certainly much more legal than going to a person who's standing on the street corner and paying the price they'll charge for one hit, rather than being able to buy a whole bottleful for less than that. So we need some kind of tracking system.

We have looked at harm reduction in Canada. We need to do that more. We need funding for that kind of service. We know that abstinence programs don't work as well, because we have some statistics that show that methadone programs have something like a 30% success rate, where abstinence programs have afforded maybe a 10% success rate.

In Canada, harm reduction is associated with drug use and the risk to individuals, families, and communities. It has shown improvement of the social and economic status of individuals and thereby reduces the costs of health, social justice, and enforcement. Somehow or another, governments are supposed to break down their towers and look at this as a social and a health issue and work together to solve it. Saying that the health department is the only one that should pay for addiction is pretty ridiculous when a lot of the money is coming out of corrections.

¿ (0925)

A third of my clients have come from Corrections Canada. Well, there's no money in the community to pay for any kind of service for people coming out on parole. It's a provincial process and a provincial problem. But it's eating up a huge piece of my funding to care, without having any input from the people who are sending me these clients.

There are a lot of these kinds of inequities in the system. Crime reduction in New Brunswick has been looked at. To date, needles are provided by the provincial government through the health department. Services are not. Therefore, there are only two needle exchange programs in the whole province, at the present time.

There really should be needle exchange programs in every city and in every small town where they're actually needed. Though there is, again, the confidentiality issue of walking into your own hometown, somewhere in a small community, and asking for needles, because there is a huge confidentiality issue around all of these things.

We do need needle exchange programs at the community level, where they're accessible to people. Access is one of the big problems here. How do you access all of these services that are very high maintenance and very costly?

In New Brunswick, methadone programs have not been funded by the government. To date, there are two that are run out of doctors' offices, and our own clinic that offers more comprehensive services because we do complete community health care, primary health care, to look after all your health programs, as well as your addiction problems.

We're offering a full gamut of services by a multidisciplinary team of service providers. I'm a nurse practitioner. We have a doctor, a nurse practitioner, nurses, counsellors, massage therapists, etc. It is a comprehensive service that's being offered, but 40 clients are almost our maximum. We have 60 clients on a waiting list. Fifty clients are going to max us out. What are we going to do with the rest of them? How are we going to say that we're offering equitable service?

The university would say that it's not their problem, it's the health care system's problem. But we are sitting on the ground with the clients. It is our problem as citizens, if not as care providers.

The Chair: You are well over time. Could you move to your recommendations?

Ms. Margaret Dykeman: I can certainly do that. I'm sorry, I don't wear a watch, so I'm waiting for you to tell me.

The recommendations that we have provided are in your brief, and I'll just leave them to you.

I'll close with that. Thank you very much.

The Chair: Thank you, Ms. Dykeman.

Now, from Dalhousie University, we have Mr. David Zitner, the director of medical informatics in the faculty of medicine. Mr. Zitner.

Dr. David Zitner (Director, Medical Informatics, Faculty of Medicine, Dalhousie University): Good morning. Thank you for taking the time to hear me this morning. I'll try not to go over my time too much.

I'll tell you a bit about myself. I'm a family doctor and director of medical informatics at Dalhousie. I've done some work on health policy, including one paper called “Public Health, State Secret” and another one called “Operating in the Dark”.

I'd like to start with a proposition, and some of the discussion around the themes of those papers. I'd like to start with the proposition that we believe that all Canadians should have access to necessary drugs. This will only be possible when we identify and pay for only those drugs that are valuable, and not ones that are merely useless and possibly harmful.

You have a copy of my speaking notes.

On a daily basis in Canada, patients have miraculous cures because of drug therapies. On the other hand, some are harmed because they can receive drugs that are useless, and others are harmed because they receive drugs that have complications.

We spend billions of dollars on drug treatments, yet it's odd that no one knows how many people have been helped or harmed by this massive injection of drugs. Was anyone on this committee ever called by the health system to find out whether you became better or worse after you took a drug? What's even more interesting is that even when the system does get the information, we don't correct it and store it in ways that make it usable to us.

There's a large therapeutic gap in Canada. Some people can't afford needed treatment because they're poor. Some are prevented from receiving appropriate and necessary drugs because they aren't covered by drug plans, and some drug plans have substantial barriers to use of even effective drugs. Sometimes as clinicians--and I include myself in the group--we don't recognize that a particular drug is necessary.

On the other hand, communities, either as individuals or through insurance, pay huge amounts for drugs that are eventually shown to be harmful—in the notes that you have, I've given two examples—or for drugs that are useless and possibly harmful.

For example, following up on the two earlier speakers, there's a paper called “The Emperor's New Drugs”, which speaks about the fact that there is very little evidence that anti-depressants are more beneficial than placebos. There are two, actually; one is “The Emperor's New Drugs” and the other one is “Listening for Prozac, But Hearing Placebo”. They're available. They're in journals.

There's also substantial waste because insurers, including government, pay large amounts for drugs that are bought but never taken. According to a recent article in a British medical journal, about half the drugs that are prescribed for chronic disease aren't even taken. Presumably, if this waste were eliminated, we would have resources available to pay for useful care.

We hear many people speaking about complex adaptive systems, including one group that Carol has been leading. Sadly, in Canadian health care, we don't really collect the information that we need to link the activities and results of care. So we are unable to develop and behave as a system that adapts and learns.

Feedback is essential for learning. We need to know what works and what doesn't. Since we can't link the activities and results of care, and get feedback about our actions in prescribing drugs, it becomes difficult or almost impossible to distinguish the valuable activities from those that are harmful or merely wasteful.

One of the thoughts that we've had, in order to allow every Canadian to get the drugs that we need, is that it would be appropriate to follow up on the works of Kirby, Romanow, and others, suggesting that we need catastrophic drug coverage with a deductible.

One of the benefits of the deductible, we believe, and following on work by the Rand Corporation, is that people who spend their own money are more likely to be cautious in the use of health care resources, and except for the very poor, seem not to be harmed.

¿ (0930)

Even Tommy Douglas, the founder of medicare, and you have his quote in the brief, recommended that people pay for a portion of their care.

We all recognize the harms that happen when health care cannibalizes some other valuable health-enhancing services, including education, recreation, and economic development. So I think it becomes very important that we act as proper stewards of resources. However, in order for either governments or individuals to know how to spend their money, they need to know whether the drugs and treatment that they get are valuable or harmful or useless.

The history of western medicine is that we've all had superstitious beliefs. We've had beliefs about certain treatments, including blood-letting.

When I graduated people had the serious and sincere belief that almost every woman who delivered a baby should have an episiotomy. The senior doctors who we spoke with all said this is terrific. They didn't mean to harm anybody, but it was a superstitious belief.

An hon. member: What is an episiotomy?

Dr. David Zitner: An episiotomy is...when a baby is delivered in order to allow the head to come out of the perinium more easily.

Actually, some people suggested that one of the reasons I stopped doing it early in my career is that I wanted to get back to the office more quickly, because then you don't have to sew up the episiotomy. It didn't make sense then, and it doesn't make sense now, and now people have data.

The British Medical Journal suggested in its October 11 issue, which the committee may want to look at, that in every generation we believe that what we're doing is terrific and we can't believe that people had false beliefs earlier on. I think that's an interesting aside.

Today certain anti-depressants are commonly used in the absence of evidence that the benefits outweigh the harms. In fact, we recently heard that Paxil, a drug that was widely prescribed to adolescents who were labelled as having either excessive-compulsive disorder or depression...actually their mental health became worse, because they had an increase in suicidal ideation. This is a whole other issue, not for this committee.

So policy-makers, health services administrators, and patients all grapple with the question of what drug to pay for, hoping to only pay for those likely to produce benefit and not harm. Without information about the beneficial and adverse effects of drugs, such decisions are merely groping in the dark. Often no one can accurately say how many people are helped or harmed by a particular drug. Decisions about what drugs to pay for would be helped by knowing the numbers needed to treat and the numbers needed to harm.

One of the ways we assess drugs in health is to say how many people must take the drug in order for one to achieve a benefit. If you think of, for example, a cholesterol-lowering agent, not everybody who takes them benefits. If you give the drug to a certain number of people, how many are harmed? Because it's very rare and unusual to have a drug that only does good for people. So we waste a lot on unnecessary and harmful care, then have insufficient left over to ensure that middle-class and poor Canadians have access to expensive but cost-worthy drugs.

One of our notions is that government as a regulator must insist that health adopt the quality practices from other industries and provide information about the benefits and harms of care, including information about the numbers of people needed to treat in order to have a benefit and the number who will be harmed by taking those drugs. Doing so would permit all of us as individuals, as policy-makers, as administrators, as clinicians to make rational choices about drugs so we can ultimately ensure that we act responsibly using our own resources and the communities' resources.

Thank you for taking the time to listen.

¿ (0935)

The Chair: Thank you very much.

We'll now move to the second part of our meeting, and that is questions from the members.

We'll begin with the critic for the official opposition, Mr. Rob Merrifield.

Mr. Rob Merrifield (Yellowhead, Canadian Alliance): Thank you for coming in. Actually, I found all three of your testimonies really quite interesting, because they reflect a lot of my suspicions.

First of all, I want to get a handle on your suggestion, Allan, that it's the therapy that you're using that actually moves people off drugs and it is more effective, more cost-effective now. Can you tell me briefly what exactly is involved in that therapy, and how long does it take?

Dr. Allan Abbass: The average course of the treatment is under 20 weeks. There's a large series; it's between 15 and 20...of patients that.... There are about 60 comparative studies done in the literature, and an average figure is about 20...provided by a psychiatrist...say, $2,000, on average, across Canada.

Mr. Rob Merrifield: So what's involved in that?

Dr. Allan Abbass: If you help a person examine what happens to emotions when they're right in your office and when they talk about emotions and how they deal with it out there, you can see how their body reacts to it. You can see that some of them actually will feel sick physically and they will get anxious or have symptoms when you focus on emotions.

The same thing happens outside the office. What you do in the treatment is help them to be aware of what happens to emotions. You make them conscious of what those emotions are so that they don't get sick and avoid emotions inside, but rather they become aware of them. They are then able to experience emotions rather than avoiding them in every which way, including going off work, going on medication, going to drugs, going to eating disorders, going to having a lot of interpersonal problems.

So it's around emotional awareness and experience of emotions and it's a new approach built on older...over the last 20 years. It's based on videotape technology. All the training and teaching is off videotapes, so they can look at the second-to-second interventions.

Mr. Rob Merrifield: So tell me, who does it work on and who does it now work for?

Dr. Allan Abbass: It works for all those conditions that I described, such as anxiety, depression, personality problems, irritable bowel syndrome, headache. There's a range of physical problems, such as fibromyalgia, substance problems as well, pain problems. There are studies on ulcers, dyspepsia, and there is other extended research on things like hypertension as well.

Mr. Rob Merrifield: So it would work on Margaret's case?

Dr. Allan Abbass: There is one study with pain that I know of. There are other studies with substance abuse.

So there are different ways people deal with emotions. We have different compartments, but it's the same thing. When you treat the emotional process all these problems seem to resolve themselves at the same time. So the phobias shrink, the depression lifts, they stop doing substances, they stop having interpersonal battles with bosses, or other things like that.

Mr. Rob Merrifield: So you don't use drugs?

Dr. Allan Abbass: No. In the study I published recently, 85% of people are able to reduce or stop drugs. Some people I do start on medications. About 3% go on medications. For about 15% we increase or decrease the level. The remainder go down or off. Between 75% and 80% are able to stop all their pills, and that includes things like hypertension medications too. So it saves a lot of money. People get off medication. And it's not a popular topic. It's not funded very much by industry talks.

¿ (0940)

Mr. Rob Merrifield: Does it work on everybody?

Dr. Allan Abbass: It doesn't work on everybody. My experience is that 80% of people benefit and maintain gains in an average of a one-and-a-half-year follow-up. So 80% is eight out of ten. But 85% of people who come to my office are candidates for the psychiatric treatment, five out of six, so it's a very large population who are candidates for the treatment.

Mr. Rob Merrifield: Now, one thing we haven't talked an awful lot about in this study is the value of nutraceuticals, of building your own immune systems up and your body up. Is that part of your therapy here?

Dr. Allan Abbass: People start to take care of themselves better, their general personal care, when they start to regulate their emotions better. A lot of the time the way people deal with emotions like anger is they harm themselves or they don't take care of their bodies, or they overeat, smoke and drink, or do things that sabotage their health care. When you treat the emotional process people take the care of their health better.

So if nutrients are helping them, or protein supplements, exercise, they start to do these things. People who have morbid obesity lose weight, for example.

Mr. Rob Merrifield: So where do you get your patients from?

Dr. Allan Abbass: They are referred from other psychiatrists, referred from out of the province, from other specialists like neurologists and cardiologists. That's in our local centre here. GPs and other psychiatrists refer to us as well.

Mr. Rob Merrifield: Are GPs, the rest of the medical field, recognizing the benefits? Is it well known?

Dr. Allan Abbass: Yes. Here in Halifax in the last year we had 300 consultations from over 100 professionals. I tabulated that recently, because we were looking at our year's data. A lot of them were specialists. Something like 70 were GPs, so that was just the local effort here in Halifax.

It's a maritime effort too, because we see people from New Brunswick. Right now the waiting list, because we have a staffing problem, is about six months for a consultation.

Treatment now is just nine sessions. And we had 30 people back to work last year, off disability. That saves the cost of the program right there. And 37 medications were stopped last year. That, on its own, almost pays for the program.

So we're saving money in the system, and we're looking for staffing to provide more of these services.

Mr. Rob Merrifield: Yes, that's the problem in most of the provinces. In fact, I haven't seen a province yet that doesn't have a massive problem with the way they deal with mental illness. So there's a--

Dr. Allan Abbass: Yes, the ratio is thirty to one of stopping meds and starting meds. It's about thirty to one. I stop thirty and start one. So people do need meds. There are people who, in my experience, do need medication and benefit greatly from it, but most people are not in that spectrum.

Everyone goes in--they're upset, they feel sad, whatever--and it's a prescription. This is epidemic.

Mr. Rob Merrifield: If you can be as frank as you can on this one, my next question is have you experienced any direct negative support from the pharmaceutical industry because of this?

Dr. Allan Abbass: I haven't experienced any direct negative support from--

A voice: What's negative support?

Mr. Rob Merrifield: Let's say lack of support, or attacks by the pharmaceuticals. Would that be better?

Dr. Allan Abbass: No. There have been drug companies, actually, that have funded talks and had me speak, so there have been some who recognize there's a need for balanced education.

As far as big funding for big conferences, maybe 1% of it goes to this kind of thing and 99% goes to marketing. That's what they have to do as a business. I totally understand that. But we're in the business of health care, and we have to do something balanced for our patients, so we need to know. Professionals need to know about these things too.

Mr. Rob Merrifield: Thank you.

I have one more question for Margaret on methadone treatment.

We've had a real problem in the last little while, since October 1, on the pricing of methadone, but that's actually with the native non-insured health benefits program. Are you seeing any problem with that? I don't know how large a problem that is for you and for the province.

Ms. Margaret Dykeman: The pricing hasn't been a problem for us because PDP, the prescription drug program, has picked it up for non-aboriginals. You're still paying for aboriginals at the present time.

I'm hearing there is some discussion about that not happening. I'm hoping it will continue, because we have a huge first nations problem in New Brunswick, and I'm just now negotiating with one of the reserves to pick up a lot of their clients and roll them into our program, because it is more all-inclusive, to give them full services.

¿ (0945)

Mr. Rob Merrifield: From the pharmacists' side of it, though, are you getting some reaction?

Ms. Margaret Dykeman: We're not getting any reaction from pharmacies. We have one pharmacy that provides our methadone and charges a service fee of $5 to everyone for it. So if it's covered by PDP, PDP pays that $5. If it's not, the clients come in and pay their own.

We have addicts who were using up to $1,000 a day--that's our maximum. They have better lifestyles and better health. About one-third of our clients have gone back to work or back to school. It's very apparent from the client perspective when they walk through the clinic that people are in much better health, having been through the experience for nine months. That part of it pretty much explains itself.

Mr. Rob Merrifield: I only wanted to know if the new pricing on October 1 had any effect.

Before my time is gone, I have one last question. Dr. David Zitner, you're suggesting that we don't know if a drug is actually working or not working because follow-up is not being done. I'm wondering how you see that being changed, and who do you see as following that up? Would that be something that Health Canada would do? Is it something that physicians are forced to do? How are you going to solve the problem? You've identified a problem, and I'm looking for a solution.

Dr. David Zitner: The paradox is that almost all of the elements necessary to solve it are in place, because, after all, when you prescribe a drug to somebody, doctors, nurses, and other workers evaluate how sick they are, what is the person's comfort function, and some estimate as to whether they're likely to die or not. After they start them on treatment and they've had the treatment, you then make a second estimate. You have to decide whether to continue the therapy or change it. So we do the measurement part--that isn't the difficult part. As doctors, we record it. We write down that information.

Mr. Rob Merrifield: So mandatory adverse reactions should be--

Dr. David Zitner: I think it's only adverse reactions because I think we want to be able to celebrate the beneficial effects as well. What we need to do as a community, and as we work with Infoway and others toward developing information systems, is I think it has to be very clear--and it hasn't been--that one of the purposes of the information system is to collect information about health status, to be able to link health service care activities with the results they produce.

You're from Alberta. In Alberta, you've recently taken an initiative to implement an electronic patient record. I haven't seen anything in the literature of that implementation that says you're going to systematically measure health status and changes in health associated with care. Unless you do that at the very beginning, unless you get that in and say “This is our purpose and we're going to do it”, it won't be done.

This isn't meant as a criticism of Alberta. I think in some ways, with regard to electronic patient records, Alberta has been advanced, as leaders. But I think if you could actually influence people to collect the information....

I'll just take a moment. I was at a health information conference. I went around to the vendors and said “How do your health records systems measure health?” You get basically a blank look.

Unless we measure health.... And for patients and for the community, you don't need to be a doctor. The elements of health are comfort. You don't need to go to school for ten years to know how comfortable somebody is. You can do it on a scale: are they in pain?

Function really isn't a highly technical issue either. The area where you do get into technical problems, advanced informatics techniques, is about estimating the likelihood of death. But even that isn't difficult.

I'd recommend that committee members look at the Pennsylvania Health Care Cost Containment Council website, where they actually give severity adjusted information about the likelihood of dying for every patient who goes to hospitals in Pennsylvania. It showed that government as a regulator can insist that communities provide the information the public needs to make choices.

I won't get into the issue about government as a regulator here. That's for another time.

The Chair: Thank you, Mr. Merrifield.

Mr. Ménard.

[Translation]

Mr. Réal Ménard (Hochelaga—Maisonneuve, BQ): Thank you.

I'm trying to grasp more fully how your system works. Let me use Quebec as an example, since I'm most familiar with that system. In Quebec, access to psychiatric services is considered a second-line resource. As a rule, a patient is referred to a psychiatrist by a general practitioner. Psychiatry is considered to be a highly specialized field. What is the procedure for referring patients to you?

I'm fascinated by everything connected to one's emotional psyche. You seem to feel that the more in touch people are with their emotions, the easier it is for them to solve their problems. I don't disagree with you. However, I don't know if we can make any generalizations about psychiatry. I'd like you to convince me further of the validity of your psychotherapy. However, let's start with the procedure for accessing services here in Nova Scotia.

¿ (0950)

[English]

Dr. Allan Abbass: The public can access our service directly. I ask them to refer through a physician, though, so I have someone to refer back to. So, family physician. Other specialists, like neurologists, cardiologists, they can refer directly. Other psychiatrists can refer directly, and mental health team members can refer directly. There are multiple routes that come to our service.

As far as effectiveness, I could show you published outcome research. I distributed a paper a few months ago when I applied to present here. I'd be happy to distribute it again, a recent one on cost-effectiveness, as one study. Then I could provide other literature on effectiveness in terms of clinical studies that show it's better than other controls. I could provide that to you.

The best evidence, however, is actually on videotaped interviews where the patients themselves describe how they're doing after versus before. I could show you the actual changes, including bodily changes, that you can see afterward, where people look stronger. I can show you demonstrable differences. That's how I teach it, from videotaped interviews, before and after, including the patient's report of how they feel after.

There are also standardized outcome measures that we use every time. These are well-established measures. That's with all of our patients who are willing to do that.

[Translation]

Mr. Réal Ménard: Several years ago, this committee questioned whether the whole issue of mental health should be examined, because at the time we heard how in the coming years, one in five Canadians would suffer from some type of mental health problem. Nowhere in your presentation did you define the word “emotion”. I'd like you to define it now for us.

As a student, I took a few university psychology courses in which I learned about primary and secondary emotions. In terms of the type of treatment, how would you rate stress and the whole question of interpersonal skills. For example, I can appreciate drug addicts wanting to overcome their addiction, but are your treatments as effective for persons who, while they may have difficulty interacting with others or managing their stress, do not necessarily suffer from mental health problems? We could be dealing with two entirely different things.

[English]

Dr. Allan Abbass: Yes, it is. It's effective for patients with personality disorders with major interpersonal problems—major interpersonal problems—self-harm, and behaviours that are destructive to their general functioning. Personality disorder populations would be one of the toughest to treat. There are four comparative studies of the treatment approach that I'm describing. This treatment is one of the most studied.

As far as specific emotions are concerned, though, we're talking about specific emotions. One of the main common ones is the emotion of anger, the physiology of anger. Most physicians cannot tell you what the physiology of anger is when you show a videotape. They get it confused with anxiety and other things that they think are actually bodily anger, anger being experienced in the body.

If you look at a series of patients that I could show you, my couple of thousand patients, it manifests as anxiety and stress in the body. It's not a feeling that's felt. It's blocked by body symptoms. What we help the person work with is to be able to feel emotion, and not have it get them sick, and not cause a bunch of problems and self-destructiveness. That's why it goes across the whole range of self-destructive behaviour patterns, including substance.

The best thing, and I'd be happy to do it, is to bring in videotape sometime and illustrate exactly what I mean. It's physiology, but it's left out of medical training. Physicians, as a group, have a lot of that problem ourselves. We can't see it in the patient, then we reach for a pill. We have a problem there.

¿ (0955)

[Translation]

Mr. Réal Ménard: As MPs, we've learned to identify and interpret certain kinds of body language, particularly in the House of Commons, but that's not what I wanted to talk to you about.

Would one of you have some thoughts about the link between the protection of intellectual property, namely patents, and drug costs? The recommendations that we will be making won't necessarily focus on treatment approaches, but on ways of reducing drug costs. Has one of you given any thought to the possible connection between our intellectual property regime and the 20-year patent protection awarded, and drug costs? For example, do any of you feel that we should reinstate a mandatory licensing system, but without the benefit of existing patent protection? Has anyone here given this matter any thought?

I find your approach very interesting and I will read your submission again when I have a quiet moment. I'd like to discuss emotions with you, but we don't have time. Let's get back to the link between patents and drug costs. Have any of you thought about this question?

[English]

Dr. David Zitner: Okay. I think that when you have drugs that are very valuable, it's appropriate to award the pharmaceutical companies properly. We hear that there are issues about innovation, and somehow we need to support innovation. The way we do it in Canada is somehow we give people economic rewards, because it seems as if the rewards of doing useful work aren't sufficient to maintain the supply of services and the necessary research.

I remember that for years as I practised, my practice was always very close to the university. I had some minor relationships with them. I actually became involved with the PhD course in pharmacology. I ended up speaking to one of the pharmacologists and asked: what's the relationship between what we do in the university and what the pharmaceutical companies do? He felt that the pharmaceutical companies made a huge contribution to new knowledge and a huge contribution to developing new products that are valuable.

I guess the paradox, unfortunately, is that your group has been elected to solve the problem. The paradox is how do we ensure that people get the services they need but that at the same time future patients have access to the innovation that's necessary to support improved health?

It's clear that other systems haven't led to the innovations that we've seen in North America. I think, as I said earlier, that we see huge therapeutic excess. What we've heard from the other two speakers is that we promote drugs that aren't valuable.

Maybe one way of dealing with the problem is that the pharmaceutical industry appropriately tries to deal with the therapeutic gap. There are people who should get drugs in Canada who aren't getting them. At the same time as they do that, there seems to be promotion of the therapeutic excess.

I think that, rather than looking at intellectual property issues, it would be more appropriate to look at the waste that comes from encouraging people to take drugs that are harmful, or not useful, and that are expensive. I'd rather pay a drug company properly for the useful drugs that they produce, and not pay anything for the things that are harmful or useless.

The Chair: Thank you, Mr. Ménard.

Ms. Bennett.

Ms. Carolyn Bennett (St. Paul's, Lib.): Thanks very much.

At the Women's College in Toronto, we had a free psychotherapy unit. As a family physician, the biggest problem was that the waiting list was a year. What would we do in terms of draining the pool?

I believe that what you're saying is absolutely spectacular. Everybody would prefer to do that, if you could get somebody in to see somebody within a week. In the meantime, you have this crying, horribly upset person in front of you and a whole waiting room. There's not a social worker, not a psychologist, not anybody else you can send this person to. How do we fix this? How long will it take to train the number of people it would require?

Frankly, most of the psychiatrists I know only do the pharmacotherapy. They won't even do psychotherapy for the patients we referred them to. They expect us to do it in some sort of shared care.

À (1000)

Dr. Allan Abbass: First of all, all we would ask is that money that is saved elsewhere in the system be distributed into education. If we can demonstrate that it saves in other areas of the system, then you could fund training and people could take their time and train. It takes, on average, two years for people to be able to work with a quarter of the population that could benefit. It's a large proportion.

Ms. Carolyn Bennett: It takes two years.

Dr. Allan Abbass: It takes two years of training of weekly videotapes, supervision, and coming to courses for people to be able to work with a quarter of the patients.

Ms. Carolyn Bennett: When you say people, are these people already MDs?

Dr. Allan Abbass: Actually, they're not even MDs. You don't need to be an MD to—

Ms. Carolyn Bennett: Are they nurse practitioners, social workers, psychologists, and GPs?

Dr. Allan Abbass: That's correct; they have to have some kind of background or to be some kind of health professional. And there's no difference between the different health professions as to who can do it, and how effectively.

Ms. Carolyn Bennett: That's for two years?

Dr. Allan Abbass: It's for years of studying pretty hard, and coming to weekly videotaped training and weekly courses, and seeing—

Ms. Carolyn Bennett: Weekly, so they're still practising and we're not taking them out of practice?

Dr. Allan Abbass: No, but they have to take a day a week to learn this. They see their patients, record their video, watch their own video, and they come to present their video, and then they get supervision feedback. On average it takes two years, so it's not a huge time-taker.

And the cost is offset. I sleep well, because for those three years in B.C. I didn't cost the government anything. My services were reduced, which led to reduced hospital and physician costs to pay for my salary. But on my salary, you could probably have three social workers for the same cost. But we have to take the time to train them.

The huge waiting list is a problem up there. That approach is a little bit different. That's Howard Brooks' program, right?

Ms. Carolyn Bennett: Yes.

Dr. Allan Abbass: That's a little bit different. This is a bit newer technology, although it has some similar principles.

So it takes a couple of years of one day a week. But GPs learn it; I have a GP coming to work with me full-time now, who had left her practice, realizing that so much of it was that kind of problem. She didn't know what she was doing in general medicine any more, because those coming into her office all had all stress-related factors. So we're converting the GPs into free psychotherapists.

Ms. Carolyn Bennett: Good. And are you training those in the family practice residency programs?

Dr. Allan Abbass: All of them get some training. Actually, all of the surgeons in our department get some training in this. We're breaking ground here, because all of the surgeons are learning how to use or understand this technology a little bit.

Ms. Carolyn Bennett: Would you say that all GPs or all certified family physicians in this country should be trained in this before they get their certification?

Dr. Allan Abbass: At least to detect when it's emotions that are causing the problem in the main.

I have a brief diagnostic test just for general family practice. I have a paper on this, which I'd be happy to send to you. It's in press now and I'm just finalizing it. It's on the request to write up how to do this diagnostic, or how to diagnose in 15 minutes how emotions are affecting the body of a person in your office.

Ms. Carolyn Bennett: I thought we just asked, “Where is your anger?”

Dr. Allan Abbass: That's a shortcut, which will work for some. But you'll see, because they get stomach cramps, a headache, and they get choked up. And then you say, “I'm not sending them to GI, but I'm just going to talk to them a little bit”. Right? “I'm not going to prescribe...but I'm going to talk to them”. Right?

Ms. Carolyn Bennett: In terms of your clinic, I guess I wanted to know how you would write a recommendation for our report. Is it about reorganizing primary care in a multi-disciplinary way, which obviously has all of the modalities you have in your clinic? How would you write your recommendation for our report?

Ms. Margaret Dykeman: I definitely think we have to go back to basic care and offer all of those services, whether they be physical or psychiatric, or whatever, through a multi-disciplinary way of doing things. Most people would not recognize the pathology that's walking around on the street if you didn't have that kind of.... We didn't know until we actually addressed it from that modality.

It is very cost-effective, because we don't send you off to this one or that one or to someplace else. And it doesn't mean there's another appointment you're not going to keep—especially with our clients, because they can't always get to where they need to go. It's all there in one place.

À (1005)

Ms. Carolyn Bennett: I guess you're saying that we need to take a therapeutic approach to drug addiction, not a punitive approach.

Ms. Margaret Dykeman: Right.

I get exceptionally angry every time I hear of the great strides we've made in taking drugs off the streets. But you still have people who are sick, or whoever that dealer was dealing with. So what are they going to do until they establish their bases again? They're going to be all of the social problems we see on a daily basis, because of the need. Yet we don't address it as an illness, but we address it from the punitive side. So it has to be addressed from both sides.

I will say, though, that we've created instability on the street with a methadone program, and to date we are dealing on a daily basis with the influence of dealers. So there is another whole piece you don't see until you start working within the community.

Ms. Carolyn Bennett: Of the methadone programs you're aware of, how many methadone tablets actually end up being resold?

Ms. Margaret Dykeman: Our program has no carry, so no methadone leaves the clinic. But there is methadone on every street in every city in Canada at the present time.

Ms. Carolyn Bennett: So you would say the direct observation treatment we use for TB would be the right thing for methadone?

Okay.

Dr. Zitner, what would be your recommendation, and how do we get the feedback loop you want? Should we all be prescribing with our BlackBerry, finding out when people haven't filled the scrip and whether it worked or not, and filing that?

Dr. David Zitner: I think that would be useful. But if you consider the government's role as a regulator, they have no trouble insisting that food companies put nutritional contents on the labels of foods. It seems to me that more than the general information we get about drugs when we fill a prescription would be appropriate, to say “This is the number of people who need to be treated in order for one to have a benefit, and these are the harms”, with some information about the likelihood of the harms.

If one looks at the material Allan's talking about, when people prescribe an anti-depressant we don't say “This is no better than a placebo, according to the literature.”

Dr. Allan Abbass: Provincially we're looking at implementing a twelve-item measure that goes in whenever you put in a billing sheet, or on a periodic basis for whatever your treatment is in mental health. It's called “Health of Nations Outcome Scale”, HONOS. There's a colleague who's an international expert in this. We're trying to get it implemented in the province. That will go right with the billing sheet; it will be part of the record. That would allow for a great deal of research into outcome and a whole range of treatments.

Ms. Carolyn Bennett: I think Dr. Zitner would say we're not data-mining the stuff we already have. Is that correct?

Dr. David Zitner: I think that's true. We're also not collecting the information about health status. The first thing is, when you give somebody a drug you should say how sick or well they are. Subsequently you need to record it and provide that information as feedback.

The Chair: Thank you, Ms. Bennett.

Mr. Robinson.

Mr. Svend Robinson: Thank you very much.

I want to thank all three of the witnesses for a very enlightening session this morning. They have three different perspectives on the issues we're addressing.

Dr. Dykeman, I want to also thank you for the work you're doing with your community health clinic in Fredericton. I was just down in Fredericton recently and actually spoke to some folks who were glowing in their praises of that work.

I'm from British Columbia, from Burnaby. My colleague, Libby Davies, represents one of the constituencies in the country that is the poorest and has devastating problems with the issues you've raised. We've just embarked, as I'm sure you are aware, on some I think quite important harm reduction strategies. A safe injection site has just opened with great controversy. Heroin maintenance is being looked at as well. But the bottom line is that lives are being saved. When you cut through everything else, lives are being saved. So I thank you for that.

In terms of specific recommendations, as Dr. Bennett has said, you've given us a number. One, for example, is the importance of expanding medicare to cover the cost of adjunct therapy, as essential services. Certainly that's one I hope we move on.

Dr. Abbass, I'm very interested in your recommendations. When I put them in the context of what we've been hearing now across the country about not just alternatives that don't involve the use of pharmaceutical drugs, such as those you've talked about—the brief psychotherapy approach—but also the very questionable alleged benefits of so many of the new drugs, and Dr. Zitner has referred to this as well, there is really only a handful of new drugs, according to much of the evidence we've had, that really have major, significant, new advantages. A lot of them are just frankly hype. I think this is a very exciting approach.

I want to ask you a couple of questions about them. Is Health Canada doing anything on this at all, to the best of your knowledge?

À (1010)

Dr. Allan Abbass: I don't think Health Canada knows about these things, really. How would they? There are no big TV ads for this; there are no billboards; there's no magazine; and there are no funds for anyone to know about it.

I put them all over the place, for example; I do, and there are other people who do as well. It's in the Medical Post—but that's only because some newsperson picked it up. It's been on CBC programs a few times, on Canada AM—but that's only if you catch those minutes. There's no momentum that gets built up, because there are not billions of dollars behind this type of treatment.

Mr. Svend Robinson: That's if you could find your article between the ads in the Medical Post. I say that kindly, because I have a subscription to Medical Post.

It seems to me this is the kind of thing Health Canada should be welcoming. It saves money in the long run; it's good for taxpayers. I think it clearly improves health. It sounds to me like the kind of thing Health Canada would want to be looking at. I certainly hope we will be able to follow up on your recommendations and encourage the federal government to really show leadership in this kind of area.

Dr. Allan Abbass: They have in the past, actually. In the 1970s a large sum of money went to the person who was the founder at McGill, named Davanloo. He gave them a large sum of money to do the ground research. From there, it has gone through a bunch of studies and it's been elaborated on.

Mr. Svend Robinson: But it's not happening now.

Dr. Allan Abbass: No, it's not, no.

Mr. Svend Robinson: Concerning geriatric medicine, one of the things I've been struck by when I visit seniors homes, for example, is the massive quantities of drugs that are used. You talk about cocktails. In a lot of these places, it's easy. I see the little containers with the drugs, and they pop the pills in, and sometimes people are just like zombies, to put it very bluntly. This is opposed to what I suspect might be more appropriate therapy that doesn't involve the massive use of drugs.

Could you talk a little bit about that? Also, one of the controversies that arose—and it's a whole issue directly linked to this issue of the boundaries between the pharmaceutical industry and educational institutions.... There's a fascinating article, by the way, by Arthur Schafer, out of the University of Manitoba, on the importance of sequestration completely. Could you talk about Prozac and some of the controversy that's arisen around the prescribing of Prozac—David Healy had something to say about that—and also about corporate influence in pushing some of these drugs that may in fact not be necessary?

Dr. David Zitner: Essentially, there is a set of articles that show that on a population level many of these drugs don't produce more benefit than harm.

Your question, which the committee probably doesn't want to get into in this short period, is about the methodologies people use. Many of the drugs are used for long terms, but the trials that have been done aren't long-term trials. In a sense, because people don't have the information they need and it isn't mandated that they get it, I think there's been some failure of federal and provincial governments, as regulators, to say that people need to have the information.

Just as an aside, getting back to Carolyn's earlier question, we actually have developed a graduate program in health informatics in Nova Scotia. We have 22 masters students. We'll have four PhD students in January. Basically, we hope they're the group of people who will be able to help governments, policy-makers, and the pharmaceutical industry get the answers they need.

À (1015)

Mr. Svend Robinson: I have one last question, if I may.

The Chair: You're actually out of time. I'm afraid we're not going to have time for Mr. Barrette to even get in, because it's 10:15.

Mr. Barrette.

Thank you, Mr. Robinson.

[Translation]

Mr. Gilbert Barrette (Témiscamingue, Lib.): Ms. Dykeman, one of your recommendations calls for the recognition of needle exchange and methadone programs as legitimate treatment programs. Are you saying that these are not currently recognized treatments?

[English]

Ms. Margaret Dykeman: In New Brunswick, no-harm-reduction programs are actually recognized by the government as being government-funded programs. I'm not allowed to call my methadone program a “program”, because it's not government funded and government supported. That's all I was saying. But they need to be picked up and recognized as a legitimate program within the health care system across the country, not just at the federal level.

[Translation]

Mr. Gilbert Barrette: I have another related question. I know that for the past two or three years at least, methadone has been approved in Quebec as a treatment for persons wishing to overcome their addiction to drugs. Have you had any discussions about this with Quebec?

[English]

Ms. Margaret Dykeman: In most provinces across Canada, harm reduction is actually recognized and supported. Actually, P.E.I. and New Brunswick are two of the last holdouts. P.E.I. has no discussion, and New Brunswick actually does discuss the problem once in while, if you keep stirring the water. But it again falls outside of the current funding practices, and therefore there has been no budget for actually year two, harm reduction modality. It just creates the regional problem.

[Translation]

Mr. Gilbert Barrette: I have one last question. This isn't the first time I've heard this. The subject also came up at a committee meeting in Ottawa where we heard testimony about the anticipated benefits of new products on the market. I believed, perhaps wrongly, that if a product or new drug was approved for use, its benefits had been thoroughly analysed. Was I being naive? Is the public naive to think that a product is beneficial?

I also have a secondary question. Why is it that if a product is known to not always necessarily have a beneficial effect, physicians continue to prescribe it anyway?

[English]

Dr. David Zitner: I think there are two parts to the answer.

The first question is why do we approve drugs? Sometimes the approval process isn't a complete analysis, which is why it's necessary to follow patients in the community. Sometimes the harms aren't apparent until the drugs have been used for a long period of time, and sometimes people feel that the potential benefits outweigh the risk of trying to use a drug.

The second question is a more important one, I think, because we do use a set of drugs on which the evidence that they're valuable is really quite marginal. In fact, for some of them, the evidence is that they're more likely to be harmful.

I ask myself the same question. I think Allan and the people around this table are trying to do something to reduce inappropriate use. To some degree, it might be a labeling problem, that people, including doctors, policy-makers, and the public, aren't really able to assess the risks and benefits, because sometimes they don't have that information.

Thank you for listening. I guess we've gone a bit over time, but I'd be glad to stay for a few minutes during the break--and I suspect my colleagues would as well--to speak with the members of the committee.

À (1020)

The Chair: Mr. Barrette, you've finished?

Mr. Gilbert Barrette: Yes.

The Chair: Thank you very much.

Thank you, on behalf of the committee, to all of you for most interesting presentations, which contained a couple of things we hadn't heard before, so that always makes it most valuable.

We'll have a short break while these witnesses leave the table and the others come forward.

À (1021)

À (1026)

The Vice-Chair (Mr. Réal Ménard): I call the meeting to order.

Welcome, ladies and gentlemen. We're going to start with Don McIver from the Atlantic Institute for Market Studies, followed by Mr. Peter Hogan, New Brunswick Pharmacists' Association.

We're going to start with five minutes, and if we need extra time, we can deal with that.

Mr. Don McIver (Director of Research, Atlantic Institute for Market Studies): I've abbreviated my remarks, so I probably don't even need five minutes. It will just leave you more time for questions.

Your committee has invited views on a number of pharmaceutical topics, and I shall attempt to respond to most of them. It is certainly true that the costs of pharmaceutical products are rising and that they constitute an increasing proportion of Canada's health care budget. I am concerned that we view those developments in an appropriate light.

New pharmaceuticals are expensive to purchase, but they are also effective. New pharmaceuticals are better than older products. They prolong lives and improve the quality of life for millions. In many instances, they replace or reduce the need for extended and expensive hospital care and intrusive surgery. To give just one example, modern pharmaceuticals have dramatically improved survival rates for heart patients and reduced the costs of caring for them.

Yes, the amount that Canadians spend on drugs is certainly rising, but before concluding that this development is negative, I believe we should understand why it is rising. A major portion of rising drug costs results from the ever-increasing number of prescriptions that Canadian physicians write.

Should that be a matter of concern? Perhaps, if Canadian doctors are prescribing irresponsibly. One must assume, however, that the great majority of the increased prescriptions are written because competent medical practitioners believe the products they prescribe effectively treat conditions that could not previously be treated by pharmaceuticals.

Surely the key is not rising costs but what we get for our health dollar. If new drugs reduce the need for hospitalization and surgery--and there's ample evidence that this is the case--then even as drug costs rise, we are saving money.

Were it not for the manner in which Canadians receive their health care, rising prescription prices would be less of an issue. Although physician and hospital services are for the most part publicly provided, some Canadians pay their drug costs out of pocket, a great many are privately insured, but about 43% of drug expenses, as you will be well aware, are paid for by governments.

Collectively, we should be indifferent about how drug costs are funded, provided that the health outcome is both cost-efficient and optimal, but individuals have widely different perspectives. An individual facing a life-threatening situation wants access to the most effective treatment, even if it is vastly more expensive than other therapies that might be almost as good, especially so if the expense is shared with taxpayers at large.

However, politicians and civil servants representing the interests of those taxpayers have a different perspective. Facing a barrage of competing plans for government spending, they are anxious to constrain overall health spending. When it comes to drug costs, they have two pools available: they can limit access, and they can control prices.

Governments limit access in several ways, the first being the process of approving the product for use by Canadians, and the second, largely a matter for provincial governments, the decision as to whether or not the treatment is eligible for reimbursement.

Canada has a poor reputation relative to the United States when it comes to the approval process, sometimes taking a year longer to certify a product. During that time, Canadians lose access to the physical and economic benefits of that medicine. The program whereby those in urgent need are allowed accelerated access to pharmaceuticals is cumbersome and secretive.

Prices are controlled in several ways. The most obvious, of course, is the activities of the Patented Medicine Prices Review Board, which determines the prices that manufacturers can charge. The result is that Americans pay 50% more for the same types of products.

Another technique that Canadian governments apply is to employ the power of bulk purchasing in conjunction with preferred product status within the health care system. A by-product of that activity is that individuals may not receive the precise medication that their doctor would prefer to prescribe to them.

À (1030)

Patent protection, or more properly its withdrawal, constitutes a very potent form of price control. Patents properly extend monopoly rights to those who have invested in the generation of intellectual property. How long they are able to retain those rights determines how much of their investment pharmaceutical companies are able to recoup and how much they are able to spend developing the next generation of products.

I think one of the questions your committee is addressing is the question of access to both new and old drugs. I have outlined some of the measures that I think constitute limits to access, but I think it would be appropriate to add one more issue with respect to access. To that list I think you want to add access to drugs not yet discovered.

New products are hugely expensive to develop. As much as $1 billion may be expended researching, developing, testing, and bringing a product to market. For every drug that is a success, dozens of experimental agents fail. The failures have to be paid for by the successes, and that is why drug patents are so important to innovation.

Canada, along with most other countries except the United States, is not paying its share of the cost of developing the drugs that we expect to benefit us. Now American politicians are wondering whether their citizens might benefit from the same price controls that we have in Canada. The reality is that were the Americans to adopt that policy, the pool of resources available to take advantage of the incredible advances in genetics will shrivel. We must be careful that the drive to supply today's patients with low-cost medicine does not deprive tomorrow's sick from the medicine they will need to survive.

Your committee has to juggle two huge issues: how to ensure that the rising demand for existing drugs is met affordably, while ensuring that those who invest in creating tomorrow's wonder drugs are rewarded for their investment.

Thank you.

The Vice-Chair (Mr. Réal Ménard): Thank you very much.

Monsieur Hogan, you have the floor.

Mr. Peter Hogan (President, New Brunswick Pharmacists' Association): Thank you.

The New Brunswick Pharmacists' Association appreciates the opportunity to address this committee.

The New Brunswick Pharmacists' Association is a voluntary advocacy membership body that represents New Brunswick professional pharmacists and certified dispensers in all pharmacy practice settings. Our members are an integral part of the health care profession. They have highly specialized scientific and technical knowledge in the pharmaceutical field. The care delivery and counselling role is the most readily accessible and least costly member of the health care team.

The two most important factors in the submission are the recognition of pharmacists as the health care profession's most knowledgeable member in the field of drugs and drug interaction, and the recognition that the knowledge is a valuable community resource, which should be utilized in the most cost-effective manner in concert with prescribers, patients, other caregivers, planners, administrators, and third-party paying agencies.

I've highlighted some of the roles of the pharmacist.

Pharmacists are clearly the most accessible health care professional in urban, suburban, and rural areas, seven days a week. Pharmacists are in a position to educate the public for better health outcomes in terms of their medication use, misadventures, and disease management.

Educating the patient to proper medication usage and compliance has proven to be cost-effective. There's some data in here that also supports that. One was done in New Brunswick at the Fredericton pharmacy initiative.

In recognition of providing valuable services over and above dispensing medications, new payment models are needed to compensate pharmacists for their counselling services. Pharmacists counsel on a number of health care issues. We've highlighted some of the major ones that we've undertaken to this point.

As stated in the final report of the Romanow commission, as part of the primary health care team, pharmacists work with patients to ensure they are using medications appropriately, and provide information to both the physicians and patients about the effectiveness and the appropriateness of certain medications for certain conditions.

The Romanow commission suggested an expanded role for pharmacists that would allow pharmacists to consult with the physicians and patients, monitor patients' use of drugs, and provide better information and communication on prescription drugs.

Romanow also commented that in the future there should be a role for pharmacists to prescribe certain drugs under specific limited conditions. Romanow also touched on the role of accountability in the health care field. Pharmacists feel that a great priority should be placed on it that currently isn't in place right now.

The registrar of the New Brunswick Pharmaceutical Society, our regulatory body, reported that one of the leading reasons for hospital admissions is drug misadventures. He has also reported that pharmacists are aware people are misusing drugs, and it's not only narcotics. The New Brunswick Pharmaceutical Society and the New Brunswick Pharmacists' Association feel that a monitoring system is necessary for optimal use of health care dollars.

The estimated costs of the misuse and overuse of prescription medication could range anywhere from $2 million to $9 million per year. This, of course, takes into account the price of the medications, as well as accessing other health care professionals' time and emergency room visits.

À (1035)

One study estimated that in 1993—and these are ten-year-old figures—these interventions saved the Canadian health care system an annual minimum of $268 million. Another study showed a 9% decrease in visits to general practitioners, a 17% decrease in visits to specialist doctors, and direct patient productivity savings of $16,500 were attributed to the initial counselling of follow-up consultations provided by pharmacists. Clearly, there is a very valuable and underutilized role for pharmacists at this point.

In touching on the Fredericton pharmacy initiative that was undertaken a few years ago, some of the stats to prove that were, for patients with gastrointestinal problems, visits to family physicians and specialists decreased by 24% and 47% respectively; for asthma patients, visits to family physicians and specialists decreased by 9% and 17% respectively; and, moreover, emergency room visits, which are some of the more costly visits to the health care system, declined by 85% for the participants when compared with baseline data.

Expanding the role of pharmacists to provide greater education and patient counselling can reduce the misuse of medication, improve health outcomes of patients, and help to lower overall health costs. It is in the public's interest to continue this process, and to expand the capability of community pharmacists to improve patient care while containing costs to the health care system. Pharmacists can contribute much more to improve health outcomes with proper initiatives that refine, execute, and pursue an expanded role for pharmacy practice.

In conclusion, pharmacists have an important role to play in the monitoring of drug therapy and advising on therapeutic values and in assessing and making recommendations to prevent or resolve drug-related problems.

The New Brunswick Pharmacists' Association believes that a new compensation regime is necessary to encourage and provide incentives for pharmacists to consult with physicians and patients, monitor patients' use of drugs, and provide timely information and communication on prescription drugs.

My brief is in fact brief. It's certainly only a quick overview. I'd be very happy to answer any questions on prescription drugs as well.

The Vice-Chair (Mr. Réal Ménard): Thank you very much, Monsieur Hogan.

We're going to start the question period with Mr. Merrifield.

Mr. Rob Merrifield: Thank you for coming in.

We've heard an awful lot from the pharmacists, actually, in the time since we've initiated the study. It certainly seems like you're pushing hard for an expanded role. Romanow recommended that, and others have alluded to it.

When you really look at this whole area of prescription medication, in light of the testimony that we heard prior to your group, I don't know if you were in the room. David Zitner was talking about making sure that if we're going to do some follow-up on prescription medication use in this country, we find out exactly whether the product is actually doing what it's supposed to do or if there's as much harm as benefit to it.

In light of the expanded role, do you see the pharmacists as being the ones who should be doing this, in conjunction with doctors as well? Would you be in a position to be able to lend your expertise to that area better than anyone else?

À (1040)

Mr. Peter Hogan: I think so, because, as I first mentioned, pharmacists are the most readily accessible. That's key in order for a successful follow-up of a patient to happen.

In the Fredericton pharmacy initiative, for example, asthma was one area that was studied. Typically, the devices used to deliver the medication, inhalers, discs, or aerosols, often inherently have some degree of potential misuse. In a lot of cases, a lot of these emergency room visits happen to occur because people aren't using the medication correctly.

It's not so much that the medicine isn't beneficial, but how they actually get the medication to help control their disease state isn't. I think that's a key area where pharmacists can help. We do already, but I think there's a more expanded role to play in that area.

Mr. Rob Merrifield: I guess you alluded to it. What's hindering you from doing it now?

You say that you want an expanded role in that area. How would that be facilitated?

Mr. Peter Hogan: The straight and dirty of it is compensation. Certainly pharmacists are paid professional fees for dispensing medication and counselling of medication. There's really no incentive beyond that to get into this area more than we are currently doing.

Certainly it is in the best interest of pharmacists to make sure patients take their medication correctly. I think there's an expanded role there.

Mr. Rob Merrifield: How do we pay you more and make that work?

Mr. Peter Hogan: In the Fredericton pharmacy initiative, for example, even if it were done based on the patient's continued health actually, the decreasing physician visits or decreasing misadventures, there would be a value to that, which could be explored. Pay a certain fee to ensure that the medication wouldn't be failing the individual or the disease state wouldn't be threatening.

Mr. Rob Merrifield: Pay pharmacists if patients don't have to go back for repeat visits to doctors.

Mr. Peter Hogan: Yes, or it could be done even with a specific fee to monitor a patient and ensure that their health outcome is consistent.

Mr. Rob Merrifield: How far is New Brunswick--that's probably what you're familiar with--away from having the medical records follow a patient?

Mr. Peter Hogan: That's on the table right now, and it has been on the table for some time. I assume you mean a monitoring system for New Brunswick. There was an inquest in a death related to a young man who had overdosed on narcotics in 1999, and from that inquest one of the recommendations was a monitoring system. Since that time, recommendations have been made, and it has certainly been on the radar of the provincial health department. Unfortunately, due to the staggering cost of it, it hasn't gone any further.

Mr. Rob Merrifield: You don't have a pharmacists' program at all that monitors that? The province of British Columbia has what's called the PharmaNet program.

À (1045)

Mr. Peter Hogan: We have nothing official. We certainly do it in our own capacity and in our own professional environment, but there is nothing beyond that in a provincial setting.

Mr. Rob Merrifield: I wasn't 100% aware of what is done here provincially. But there is nothing to that degree.

Mr. Peter Hogan: There is nothing to that degree, actually, no. We keep lobbying the government to investigate it more. I think, unfortunately, with prescription drug abuse, that seems to be putting the issue on more of a higher priority, but it's still a distant view.

Mr. Rob Merrifield: I don't know if you have any statistics on it, or maybe just your personal experience would tell you, but are we seeing multiple visits to many different doctors? We had testimony this morning here and we're hearing that is a serious problem. I wonder to what degree you are seeing that in pharmacies.

Mr. Peter Hogan: Certainly there are many facets to that. In New Brunswick, for example, there has been a shortage of doctors, and to some degree that does affect patients seeing different doctors and having to see different doctors for medication renewals, or disease follow-up, and that sort of thing. But it is certainly an area of concern. Some third-party payers do have the capability of advising us when someone has seen another doctor for the same medication. There is some drug utilization review done at that point, but it's hit and miss at best.

Mr. Rob Merrifield: I'm going to repeat the question I had this morning on methadone for the non-insured health benefits program. That has been changed as of October 1. Is that going to impact your delivery?

Mr. Peter Hogan: It is, very much. Actually, I was quite interested when I did hear that being brought up. In New Brunswick we certainly have a large population of native clients, and certainly there is a large number of methadone subscribers to that program. The Health Canada decree that came down on October 1 certainly did cut compensation by up to 50% for that service, so, yes, there are a lot of methadone providers at this point who are actually considering whether it is advantageous to continue that business. Compensation is one thing in order to make it viable, but in terms of the cost to the other business they run, is it really worth it, or is this a situation where they happen to charge the patient for the difference it costs--

Mr. Rob Merrifield: If there isn't a change, are you planning to withdraw the service?

Mr. Peter Hogan: That's being discussed currently, yes.

Mr. Rob Merrifield: Getting back to Don, on the pharmaceutical side and the patent law, you're saying the new drugs are what's being held up. Our price review board is one of the mechanisms by which you're saying that has happened. We've had conflicting testimony on this one from the price review board itself, as well as from another agency I was talking to, with regard to how long it takes to approve a drug--or the pricing of a drug, not only approving the drug from the price review board--and whether there are actually drugs that are held off the Canadian market because of the way the price review board works in Canada. Are you aware of any specific drugs that are held off?

Mr. Don McIver: I'm not a health professional, and I'm not even a health economist; I am an economist. But I do understand that is the case. I cannot tell you the specific drug, but I--

À (1050)

Mr. Rob Merrifield: I wondered if your research looked at that at all.

Mr. Don McIver: No, that's far too specific for the type of--

Mr. Rob Merrifield: Fair enough. I might as well ask the question because you're going to get it from somebody else anyway. In terms of this whole concept of drug costs in Canada and our patent law, is it tight enough? Is it too loose? There are different views on it. It's always the balance between whether we're going to stimulate the research to be done here in Canada and are we going to get the best pricing available for brand-name pharmaceuticals in the country, and I don't know where your analysis has taken you on that, but I know you've mentioned quite a bit about it here. Where do you see our patent laws in Canada as being? Are they about right? Should we be clamping down? Should we be creating a better environment?

Mr. Don McIver: I'd like to try to address the issue in terms of access, as I suggest, to existing products, but also access to new products that are about to be developed.

I don't think there's an easy answer to the question you're asking. It's not as if you can plug it into an equation and come up with the optimal resolution. Yes, clearly if you devote 100% of your GDP to pharmaceutical costs you have reached the limit. Clearly if you under-provide funding to the development of new products, that will result in an adverse outcome for Canadians. Finding that balance is, I appreciate, difficult.

Again, it's not just the patent laws. It is obviously any form of price control that limits the flow of funds into the research pipeline. I find it very regrettable that at the present time, when the human genome project--the mapping of the human genome--is complete...that allows for a very much more focused medical intervention in the future. New products that can be developed can be developed with much more specific abilities to tackle some of the more chronic health problems we have.

How is that going to be funded, is the question that lies in my mind. There has to be a balance. The pharmaceutical companies have to be rewarded for their development of intellectual property, but by the same token--and I suppose probably the most glaring example is the situation in Africa with respect to AIDS--some means, from a humanitarian point of view, have to be made to provide individuals with cost-effective treatments. It is a balance.

I'm concerned that there appears to be very little work done in this country, or in fact elsewhere, towards identifying that. It doesn't seem as if that problem is on the radar screen.

The Vice-Chair (Mr. Réal Ménard): Thank you, Mr. Merrifield.

We'll move to Mr. Robinson.

Mr. Svend Robinson: Thanks very much, Mr. Chair, and thanks to the witnesses for appearing.

I'm from the other end of the country, from British Columbia, and I want to get clarification on the Atlantic Institute for Market Studies. The last time I saw it in the news I think it was sponsoring Mike Harris' speech out here, but I'm not that familiar with the institute.

How are you funded? Do you get any funding at all from pharmaceutical companies?

Mr. Don McIver: No, not to my knowledge, and we do not receive any money from government.

Mr. Svend Robinson: You're funded through the private sector?

Mr. Don McIver: Through the private sector totally.

Mr. Svend Robinson: But you don't know if you get any money from pharmaceuticals?

Mr. Don McIver: I do not believe we do.

Mr. Svend Robinson: You might want to come back to the committee with that information.

Mr. Don McIver: Certainly.

Mr. Svend Robinson: It certainly would be helpful.

On the final page of your brief you say:

Now American politicians are wondering whether their citizensmight benefit from the same control practices that hold Canadian pricesdown. The reality is that, should the United States adopt such policies....

You're basically say that's a bad thing.

What are the control practices to which you're referring that hold Canadian prices down?

Mr. Don McIver: The whole range I iterated, in terms of outright price controls, abbreviated patent life--

Mr. Svend Robinson: Abbreviated patent life is 20 years.

Mr. Don McIver: Well, in fact it isn't. My understanding is quite clear that the actual practical lifespan of patents in Canada is substantially lower than they are in the U.S.

Mr. Svend Robinson: Could you explain that?

Mr. Don McIver: Sure. When you apply for a patent, the clock starts ticking immediately, but you cannot put the product on the market until it's gone through all the necessary regulatory reviews. Again, I'm not sufficiently well-versed in the numbers to be able to tell you X and Y, but it is several years shorter in Canada than it is in the U.S.

Mr. Svend Robinson: Before the drug is approved.

Mr. Don McIver: No, no. The active life of the patent is shorter, because during the commencement period when the patent is in place for 20 years, you're not able to market it at that stage. So the time you get to market it until the time the patent expires is shorter.

Mr. Svend Robinson: We certainly haven't had much evidence to that effect from anybody so far, so this is interesting. Are there any other practices you're talking about, control practices that hold out--

Mr. Don McIver: The formularies, of course.

Mr. Svend Robinson: Formularies are provincial. You don't agree with the formulary approach.

Mr. Don McIver: I'm simply pointing that out as another control.

Mr. Svend Robinson: But you're saying it shouldn't be there.

À (1055)

Mr. Don McIver: No, I'm not saying that. I'm saying it is another control factor. As I've just alluded to in my previous answer, I think there is a balance to be developed between the needs of those who need access to low-cost products and those who need access to tomorrow's products.

Mr. Svend Robinson: So do you support formularies or not, Mr. McIver?

Mr. Don McIver: No, I'm not--

Mr. Svend Robinson: What is your position?

Mr. Don McIver: I'm saying we need to monitor them and the outcomes their activities have. For me to come out and say yes or no under any circumstances or under one extreme or the other would be inappropriate.

Mr. Svend Robinson: Well, you've done that in your brief. You say if the Americans adopt policies like formularies, that's bad.

Mr. Don McIver: No. I'm saying if the Americans adopt the type of control, the degree of control, over price and availability that we have, the outcome would be that new products would not be developed.

Mr. Svend Robinson: That includes formularies.

Mr. Don McIver: Well, they have formularies. I mean--

Mr. Svend Robinson: I think it's pretty clear what you're saying.

To Mr. Hogan on the methadone issue. By the way, I've given notice of a motion, which hopefully the committee will be dealing with this week, if the full committee meets, that would call for an immediate suspension of this policy, partly because, as you know, there was absolutely no meaningful consultation with either the CPA, the Canadian Pharmacists Association, or with the Assembly of First Nations, or with anybody else. It was just imposed. So I'm hoping that this committee will send a strong message to help Canada back off on this.

Because there's very little time, I have time for only one question, I think. Perhaps you could enlighten us on the issue of Internet pharmacies from a New Brunswick perspective. We've heard evidence in Manitoba, where there's quite a strong industry. There was kind of a debate as to whether or not this was a good thing or not a good thing. Certainly, if you open up your e-mail, the only thing you get more e-mails on is probably Viagra and increasing the size of your penis. But certainly Internet pharmacies are way up there, and all sorts of promotion of Internet pharmacies.

What's your take on Internet pharmacies from a New Brunswick pharmacist's perspective? Is this a concern, and are there any controls in place in New Brunswick on this?

Mr. Peter Hogan: At this point, no. To some degree we've been somewhat sheltered by that. It's mostly been a western phenomenon to a large degree, although as I speak, I know there are two or three pharmacies that have opened up in New Brunswick in the last few months that are engaged in this practice.

Yes, I think there's a public health concern here. I think a lot of these larger western companies that are currently involved in this can see the east in a couple of ways. They can see it as an easy source for medications. Certainly, we do receive mailings asking us to basically fluff up our orders so we can sell them medications in instances where some pharmaceutical manufacturers may be cutting them off.

Mr. Svend Robinson: This is in Manitoba.

Mr. Peter Hogan: Yes, or out west in general. Certainly, that's an area that really.... It can also lead to areas where there can be shortages in medications later on down the line that can directly affect my patients as well. There's also an issue there where the supply pharmacies are drying up in some of these other provinces because there are so many that are involved in the Internet pharmacy and they're looking to smaller provinces, like New Brunswick or out on the east coast, where they can re-establish operations and service the eastern U.S. as well.

If there is a medication incident, the breadth of the investigation or the cost of such investigation to determine who is at fault, and from the regulatory side in New Brunswick, could be enough to bankrupt our province's societies, really, in dealing with the prescriber. In Maine you see the patient, or in New Mexico, and the drug goes through Manitoba. In order to follow all that up, there is a real potential to upset, certainly, the viability of regulatory bodies on the east coast.

Á (1100)

[Translation]

The Vice-Chair (Mr. Réal Ménard): Thank you, Mr. Robinson.

You have the floor, Mr. Barrette.

Mr. Gilbert Barrette: Good day. My comments are directed to the New Brunswick Pharmacists' Association. I assume the New Brunswick Pharmaceutical Society's role is to protect the public, like other provincial societies. I assume you'd like to make some recommendations regarding the type of control system you would like to see in place.

[English]

Mr. Peter Hogan: Do you mean in terms of the budget for health care studies?

[Translation]

Mr. Gilbert Barrette: It could be in terms of the budget. However, I'm concerned about the effectiveness of certain products that are marketed. On several occasions, we've seen how a product, while not necessarily effective, is certainly more expensive.

[English]

Mr. Peter Hogan: I'm glad you mentioned that, actually.

I think the practice right now is that the new drugs developed on the market are usually marketed to physicians from the manufacturer's perspective. So I think there's an inherent bias there right now. As well, there is certainly a great amount of financial resources directed at lobbying efforts and at enticing physicians to endorse these products.

I think one very good answer to that is actually a practice currently under way in a number of provinces, including one here in Nova Scotia and one in Saskatchewan that I'm aware of. It's called drug detailing, where a pharmacist actually goes around to visit the doctors in the province just to provide unbiased scientific data on the medications themselves. So the doctors can actually see where that drug fits in among the other drugs in that class. I think that's a tremendous opportunity. It has worked well in Saskatchewan, and it's working well in Nova Scotia.

I could be wrong, but I think there's currently a process similar to that in British Columbia.

But it seems to work great. The physicians love it. It's very cost-effective, very unbiased, and truthful information.

[Translation]

Mr. Gilbert Barrette: I'd now like to talk about the role of the community pharmacist. What do you think his or her role should be? Should the pharmacist advise the CLSCs? What are community based health services called in New Brunswick? What role would this pharmacist be called upon to play? Where would he or she work?

[English]

Mr. Peter Hogan: There are 165 pharmacies in New Brunswick, ranging from the most remote communities to the more urban settings, and they are typically located in the community itself. The pharmacies migrated from a position where at one time medication was written on a piece of paper, you basically had the medication passed to the patient, the patient walked out the door, and whether the medication worked for them or didn't.... From your point of view, you really couldn't supply any information on the medication.

Fortunately, that has migrated to the point now where we actually counsel on the medications and how to use them, to give patients a lot of information on precautions, side effects, and interactions, to the point where we're actually moving into disease state management, giving people information on basically any disease.

The questions range from...anything. They can be from disease state management to monitoring of conditions, for example, in diabetes and how to monitor blood glucose levels, and immunization questions. The realm of questions you receive in a day....I certainly think pharmacists have migrated to a much more information-sharing profession from their more distributive function in years past.

[Translation]

Mr. Gilbert Barrette: Their duties would be a combination of what general practitioners do and what pharmacists do before filling a prescription, that is advise the patient or customer.

[English]

Mr. Peter Hogan: Certainly, we're taking on a lot more of a consultative role than we have in the past. Yes, definitely. As I say, we are probably the most readily accessible health professionals. You can walk into a pharmacy at any time to talk to a pharmacist, and he or she is right there.

Yes, there certainly is a lot more information there. I think it has helped. I know that physician workload has been a big concern in New Brunswick, for example, in terms of being able to handle what may seem to be minor questions and being able to return answers to them in a timely and efficient manner. Pharmacists certainly have picked up a lot of the slack there. Gladly, it's the area we'd like to be moving into.

Part of my presentation here today was that pharmacists are open to expanding that role. It's certainly something we've wanted to get into more and more.

I didn't have a clear answer for Mr. Merrifield on compensation models because we haven't actually looked at any formally. It's certainly something we'd like to work on with the government to develop.

Á (1105)

[Translation]

Mr. Gilbert Barrette: Mr. McIver, on either page 3 or 4, you note that the committee should consider “access to drugs not yet discovered”. Is this a reference to research? What exactly do you mean by this statement?

[English]

Mr. Don McIver: Yes, precisely that. We have seen a tremendous surge of new products come on the market in past decades. Many of them have made meaningful changes in the way in which we treat people. We must find a way of balancing, as I suggested earlier, the need to ensure that everybody has access to those products, but also the ability of the pharmaceutical companies to engage in research and development and bring new products to the market.

I think we may see the development more of pharmaceutical service companies that will actually undertake the research on behalf of some of the major pharmaceutical corporations. If that develops, then I think we will be in a situation where the costs facing the pharmaceutical manufacturer will become clearer and perhaps resolve some of the concerns that people around this table have with respect to the role of the pharmaceutical companies.

The Vice-Chair (Mr. Réal Ménard): Thank you.

The last speaker is Ms. Bennett.

Ms. Carolyn Bennett: Thanks very much.

I was on a drug reform secretariat in the 1990s, or sometime, on the subcommittee on the expanded role of the pharmacist in Ontario. That was when pharmacare meant a more consultative role for pharmacists, as opposed to who paid.

In the current way that pharmacists are remunerated, and you allude to it in your brief, you don't get paid if you tell somebody they don't need a drug. What exploration would there be in changing the way pharmacists are remunerated for a consulting role, as opposed to being paid as a vendor?

Mr. Peter Hogan: Certainly, Quebec actually has a very good example of that currently, where a pharmacist has a right to refuse to fill a prescription if, in the pharmacist's judgment, it's deemed that it's not appropriate or there's duplication of medication. There is certainly an enticement for that kind of thing.

That's not to say that currently pharmacists should fill the number of prescriptions just to get the fee, basically. Certainly, we do have the patient's best interest at heart. If there was a medication that wasn't appropriate for that person, for whatever reason, it's not being filled now.

I think the Quebec example is probably a very good example of what you're asking. It has worked well there in terms of pharmacists being able to give that right of refusal. It certainly is a good endorsement of a pharmacist's professional judgment.

Ms. Carolyn Bennett: Things like using a puffer or taking the foil off a suppository--all of those things take time. I guess there have been remarkable pharmacists who then set a standard in a certain community that everybody else has to follow. Apparently, there were pharmacists in Sault Ste. Marie. I think there were many examples.

How would we change the remuneration of pharmacists such that it really was about the value of the service? Do we have to change the whole thing such that the pharmacist becomes a member of the health care team in terms of primary care reform?

Mr. Peter Hogan: I think the pharmacy would like to have more of an inside voice. I think we have a lot more to bring to the table than we have been given credit for in the past.

There are some examples. For example, in Ontario, the Ontario Pharmacists' Association began a thirty-day trial prescription program on the provincial drug plan. It was an idea that came from pharmacy inherently to help reduce the cost of medication that doesn't work out for the patient for whatever reason, be it adverse effects or to cut down on medication wastage.

I think pharmacists, if they were involved more on the inside, would have a lot more ideas like that. We see things on the front lines, where medication dollars are being wasted, health care dollars are being wasted. That experience, I think, would be a lot more helpful to help the planners and primary health care delivery.

Ms. Carolyn Bennett: Do you think there's a difference between pharmacists in chain drug stores and in pharmacist-owned local pharmacies? Do you think the pressures on the profession are different?

Á (1110)

Mr. Peter Hogan: Oh, I see. That's an interesting question. I don't think so. We all have the same certification. We all go through the same schools. Certainly, the work environment may be a little different in those two different settings, but in terms of the integrity of the individual, I think they'd be equal.

Ms. Carolyn Bennett: In the expanded role, I guess hospital pharmacists do end up very much a part of the health care team.

For some chronic conditions like hypertension, are there models that the pharmacists have explored, where patients could bring in monthly blood pressure readings from their own cuffs, and the pharmacist would then determine whether or not the patient needs to see the doctor and whether the renewal could be filled?

Mr. Peter Hogan: Definitely. I don't know if there have been any formal studies in that area.

I know the Fredericton pharmacy initiative done a few years ago resembles what you are saying. For patients with asthma, for example, the respiratory function was tested. Certainly, we reinforced the proper and correct use of devices.

To some degree, that already happens with diabetes management, where pharmacists actually monitor it. Patients often bring in their blood-glucose meters. You can chart how their blood-glucose levels fall, if they're high or low.

I think a lot of that currently does go on informally. I don't know if there have been a lot of formal studies. The Fredericton pharmacy initiative is probably the only example I can presently call to mind.

The Vice-Chair (Mr. Réal Ménard): Last question.

Ms. Carolyn Bennett: Do you have any evidence in terms of white-coat syndrome and hypertension? If the patients are taking blood pressure themselves or maybe even doing it at the pharmacy, would we end up with more accurate readings and treatment?

Mr. Peter Hogan: That has been a term that has been bantered around for a number of years, and I think there is some truth to it. I think to some degree there's some truth to that even in the pharmacy.

I know that if I walk over to a patient at the blood pressure machine and I have the white coat on, standing above them looking down, and this thing is squeezing their arm, obviously there's a little anxiety. Definitely, in their own homes they might be more relaxed, so you might get a truer result. I don't have any quantitative data on it, but that's my gut feeling.

The Vice-Chair (Mr. Réal Ménard): Thank you.

On behalf of all the members of the committee, thank you for coming.

We will have a five-minute break, and we will see you next time.

Á (1113)

Á (1125)

The Chair: Good morning. We'll come back to order now and begin our next session.

I welcome you on behalf of all the members of the Standing Committee on Health. If you have submitted a brief, you'll find that they're very fast readers.

Thank you for coming.

We'll first hear from the representatives of the Canadian Cancer Society, the Nova Scotia division, Meg McCallum and Steve Machat. I see Meg McCallum.

Ms. Maureen Summers (Executive Director, Canadian Cancer Society - Nova Scotia Division): Good morning.

We've changed our speakers. I'm Maureen Summers, the executive director of the Canadian Cancer Society, Nova Scotia division. I am joined by Meg McCallum, our director of programs. My travel schedule changed, so I was able to be here today.

In addition to my speaking notes, members of the committee will also find a background briefing note providing an overview of financial assistance programs available to Nova Scotia cancer patients.

On behalf of our volunteers, our staff, and our supporters, I am pleased to be speaking with you today, and thank you very much for this important opportunity to share our concerns about an issue that is creating undue hardship for cancer patients and their families.

Ms. Carolyn Bennett: We don't have your paper.

Ms. Maureen Summers: Current Nova Scotia government financial assistance policies that are intended to help cancer patients with the high cost of cancer drugs and treatments are denying many patients access to the medically necessary medications and treatments they need, further placing at risk their health.

Why is this the case? Advances in cancer drugs and treatments are changing the nature of how cancer care is delivered. As these advances make treatments more available in the home, our public policies have not kept pace with these changes. Rather, our policies and what the health care system ultimately funds are still rooted in the hospital-based care delivery method. As a result, cancer patients and their families face serious financial challenges, forcing them to make decisions that compromise their health and in some cases dictate their survival.

Let me put this in perspective for you, ladies and gentlemen of the committee. If you were a cancer patient living in Nova Scotia and you and your family had an annual gross income of more than $15,720 and you did not have third-party medical insurance, you would not qualify for the Nova Scotia government's financial assistance program for cancer patients. You would not have coverage. You would find yourself in a terrible position of having to make the types of decisions cancer patients and their families face daily. Throughout the winter we hear from families and cancer patients who are faced with the decision as to whether to heat their house by paying for oil, or to pay for their medication.

Patients discharged from hospital after surgery often suffer extreme pain because they cannot afford necessary pain medication. You may be quite familiar with the Oxicontin situation in Cape Breton that captured the attention of national media. Oxicontin is a narcotic prescribed for pain relief. Cancer patients are selling a portion or all of their Oxicontin to narcotic addicts, thus not controlling their own pain in order to pay for other treatments or basic life necessities like food, shelter, and clothing.

Our volunteers and staff hear from men living with prostate cancer who elect surgical castration because they cannot afford Lupron, a commonly prescribed hormone therapy injection that costs $6,000 a year.

We hear from oral cancer patients who cannot afford tooth extraction or dentures after radiation therapy has destroyed the integrity of their teeth.

We hear from patients who cannot tolerate a regular diet but are unable to pay for the cost of nutritional supplements, so they try to survive on the few foods they can, further exacerbating their bodily health when their systems are already compromised.

Patients who choose not to take their medications as prescribed in order to stretch out how long the prescription will last so they don't have to pay for refills as often are undermining their treatment regime and potentially their survival.

The stories and experiences cancer patients share with us on a daily basis tell us not only that the economic burden of cancer affects a family's financial health, but it dramatically impacts their physical and emotional well-being, and, just as importantly, their dignity.

Á (1130)

Ladies and gentlemen of the committee, we trust that having learned more about the decisions that cancer patients and their families in Nova Scotia are forced to make every day, and the consequences of those decisions, you'll put forward recommendations that will enable cancer patients and their families to focus on what's most important when facing a cancer diagnosis: winning the battle against cancer.

We're encouraged that federal, provincial, and territorial governments are acknowledging the challenges that cancer patients are facing. Our hope is that decisions made by government are in the best interests of cancer patients and the continuing viability of the health care system.

The first ministers' accord signed earlier this year promised to ensure that by 2005-06 no Canadian should suffer undue financial hardship for needed drug therapy. This is a welcome development and another step in addressing the challenges that cancer patients and their families face when they do not have or cannot afford insurance. Yet based on what you've heard in the last few minutes, surely you would agree that there is still significant progress to be made. We hope your findings will be used to continue to engage and encourage the federal, provincial, and territorial governments to follow through with what's outlined in the accord. As well, we encourage all levels of government to work with the pharmaceutical industry to contain the cost of medication.

In concluding my presentation, I would like to emphasize that your work can help to create a health care system where no Canadian is forced to suffer undue physical or financial hardship when facing a diagnosis of cancer.

Thank you for this opportunity to address you.

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

Our next witnesses are from the Nova Scotia Citizens Health Care Network: Ian Johnson, the vice-chairperson of the network; Sheila Richardson, from the Council of Canadians; and Peggy Brown, representing the disabled. These three have agreed to share their five minutes.

Mr. Johnson, are you first?

Mr. Ian Johnson (Vice-Chairperson, Nova Scotia Citizens Health Care Network): Yes, thank you, Madam Chairperson.

We thank the committee for the opportunity to speak to you. Being a true coalition, we're going to try to share the time.

For us, the cost and access to prescription drugs has long been one of the most pressing needs for public health care, and in our view, nothing can do more to help enhance or, on the other hand, to undermine proper care and treatment than access to needed prescription drugs.

I will provide a brief bit about us. We have been established since 1996 here in Nova Scotia. We're a provincial network including seniors', women's, anti-poverty, persons with disabilities, and community groups and labour organizations. We're affiliated with the Canadian Health Coalition and provincial health coalitions across the country, and we are dedicated to protecting, strengthening, and expanding medicare. As a result, we believe fundamentally in the basic right of all Canadians to health and health care and in health care being a public service that we all have a collective responsibility to make accessible and available to all Canadians, regardless of background, circumstances, or geographic location. We think this is a basic right and a collective responsibility that can best be exercised through a publicly funded and operated system, consistent with the five basic principles of the Canada Health Act.

As did our colleagues who were just before you, we want to give you a sense of some of our major concerns about the present situation in our province.

We don't have a universal prescription drug program, but there are four specific drug programs funded and operated by the Government of Nova Scotia: the Nova Scotia seniors’ pharmacare program; the community services pharmacare program for clients who qualify under income assistance, and also the community supports for adults program; the program you've heard more about from our colleagues just before us, drug assistance for cancer patients; and the multiple sclerosis drug funding assistance.

I will now turn it over to my colleague Peggy Brown, who wants to make you aware of specific concerns for persons with disabilities and people on fixed incomes with regard to the present arrangement.

Peggy Brown.

Á (1135)

Ms. Peggy Brown (Disabled Individuals Alliance Representative, Nova Scotia Citizens Health Care Network): I represent persons with disabilities, and I want to give you some concerns we have with obtaining drugs to live in the community.

First of all, persons with disabilities can't get proper drug coverage to get their drugs to keep them functioning. There are a long list of medications that aren't covered, such as narcotics for pain medication, medication for arthritis, coverage for diet suppressants for obese people, and eye drops for the visually impaired, who basically can't survive without some of these drugs, especially people who have glaucoma or who have had cornea transplants.

I've also heard that there is a program available now where you can get this card and go to a pharmacy and get a pain patch to help with the pain. I've just found out about this. I'm learning about this.

There is also a program where income assistance people who need long-term pharmacare coverage can get a card that will help them go to the drug store and get the medications they need over and above their social assistance program.

The other program is the seniors program, which I'm just learning about also. When seniors become 65, they're switched over to a pharmacare program that has a co-pay of $336 per year, and then a capped co-pay of $30 on top of that if they don't apply for income assistance to have this coverage wiped.

I forgot one thing about the income assistance program. If a person has any more than three prescriptions, they have to pay for their co-pay.

That's all I have to say.

The Chair: Ms. Richardson.

Ms. Sheila Richardson (Valley Chapter, Council of Canadians, and Member of Health Network, Nova Scotia Citizens Health Care Network): I represent the Valley Chapter of the Council of Canadians.

We believe the time is long overdue for concerted federal, provincial, and territorial action to deal with the costs and access to prescription drugs, as recommended in the 1997 National Forum on Health report:

Because pharmaceuticals are medically necessary and public financing is the only reasonable way to promote universal access and to control costs, we believe Canada should take the necessary steps to include drugs as part of its publically funded health care system.

They called for a carefully planned course leading to full public funding for medically necessary drugs.

Guy Caron from the Council of Canadians presented a submission in Ottawa, which we fully endorse, that states the provinces buy their drugs separately. If all 13 provinces and territories joined together, then we could buy in bulk and save money.

In our view, this carefully planned course has several key elements: ending, or at least reducing, the 20-year patent protection that has existed for 12 years for brand-name drug products by multinational drug companies; stopping the current pharmaceutical industry practice of evergreening in which brand-name drug manufacturers make variations to existing drugs in order to extend their patent protection; and fully implementing the six recommendations of the Romanow report with respect to prescription drugs, especially those concerning a new catastrophic drug transfer, a new national drug agency to control costs and evaluate new and existing drugs and establish a national formulary for prescription drugs.

We'd like to protect Canada's health care system from possible challenges under international law and trade agreements, as recommended by the Romanow report. With chapter 11 of NAFTA, WTO, and the free trade area of the Americas, the multinational companies can sue national governments if and when they protect their country in terms of provision of a public health system. If they sue, the national government stands to lose large sums of money due to perceived lost profits of the drug companies.

The new deal that was struck in Doha, TRIPS, does not prevent the member countries from using their own generic drugs to protect public health for catastrophic illnesses such as HIV/AIDS instead of the more expensive brand-name drugs.

A committee was set up to allow poor countries with little or no manufacturing capacity of their own to import generic drugs from other countries. The U.S brand-name pharmaceutical companies have strongly opposed these moves at the end of 2002. They have pressured American negotiators to limit both the number and kind of the diseases that can be considered a public health crisis as well as conditions under which countries could import generic drugs. The industry lobby targeted key Republicans for re-election in order to have the U.S remain firm in its opposition to any easing of the TRIPS deal.

So we would like to recommend that TRIPS be continued and that member countries be allowed to use their own generic drugs to protect public health.

Á (1140)

The Chair: Thank you, Ms. Richardson.

Our next presenter is from the P.E.I. Health Coalition and the MacKillop Centre for Social Justice. This morning we have the chairperson, Mary Boyd.

Ms. Boyd.

Ms. Mary Boyd (Chair, P.E.I. Health Coalition; Director, MacKillop Centre for Social Justice): Thank you very much, Madam Chair.

The Prince Edward Island Health Coalition extends sincere thanks as well for the opportunity to express our views on these important issues of prescription drugs.

The coalition was founded in 1979 when Island doctors began to opt out of medicare to extra bill. It's one of the oldest provincial coalitions. It's affiliated with the Canadian Health Coalition and acts in solidarity with other provincial coalitions in this country.

We believe the large, powerful pharmaceutical companies have far too much power and exercise too much influence in policy-making in Canada. They are a major obstacle to the improvement and affordability of Canada's public health care system. We endorse the five founding principles of Canada's public health care system and the recommendations of the Romanow report.

Prince Edward Island has the lowest public prescribed drug expenditures as a percentage of prescribed drugs of any province or territory in Canada. Madam Chair, there is much inequality of access to affordable medicines in this country. Our drug costs and rate of prescribing in this region are very high.

In Prince Edward Island, where workers earn the lowest weekly wages in Canada and work the longest hours to earn even that level of wage, the cost of drugs is an enormous burden. These wage earners are often the ones who have to undergo demeaning means testing, a practice that would end if we had a national pharmacare program, which our coalition supports. The public bears too much of the burden.

Just to give you an example, in Prince Edward Island the rate of people admitted to hospital for asthma is the highest in Canada, and the rate in general is very high. It takes an average of three puffers a month for people with asthma. At $100 a puffer, you can imagine the cost to people who suffer from asthma.

I'm going to go on to our recommendations because of the shortness of time. I want to begin by saying that the P.E.I. Health Coalition endorses the Canadian Health Coalition's recommendation that an independent public inquiry into the pharmaceutical industry in Canada be conducted before any decisions are made pertaining to the federal plan to (a) renew health protection legislation, (b) speed up the drug approval process, (c) permit direct-to-consumer drug advertising, and (d) adopt its intellectual property framework to enable Canada to be a world leader on emerging issues such as new life forms.

In advance of this, we ask the committee to find out what percent of the therapeutic products directorate comes from user fees. We know that in the United States about half of the budget for evaluation of new drugs comes from the drug companies' user fees. That makes the agency dependent on the industry it regulates. In Canada the pharmaceutical companies pay $40.7 million a year to the therapeutic products directorate, but the figures for drug evaluation are hidden.

Á (1145)

I think that's a very important issue that we have to dig out. We hope you will be able to do that, because there is a conflict of interest there and it needs to be attended to. Accountability and transparency in this area and other areas are very important to the improvement of health care delivery in this country.

Secondly, we recommend that the level of publicly funded drugs in the Atlantic provinces be increased to the national average, that the level for catastrophic drugs be set after this goal is achieved, and that a percentage of income become the formula rather than a flat rate. We believe that without that we could fall even further behind. Of course, we understand the urgency of enacting the policy of catastrophic drugs--we really do--but we believe that before doing that we should look more carefully at the best way to do it.

Also, we recommend that the practice of evergreening drugs be discontinued and new drugs be subject to a truly scientific procedure, as outlined by the Canadian Health Coalition, that is transparent, systematic, peer-reviewed, independent, accountable, and open to learning. Canada is now the only country in the world that continues this practice. We recommend that the practice of evergreening be ended in the interest of improving access to cheaper generic drugs for Canadians and to help contain the escalating costs, which threaten the future of medicare.

I think I had better refer to my sheet with the other.... I was working on the boat coming over, and when I got on my laptop I found I didn't quite have all my notes in sync.

The next recommendation is that the federal government practice of funding independent research on pharmaceuticals be restored and that the practice of commercialization be diminished. If I have time, I'll elaborate on that. Also, we recommend that a universal system of public financing of pharmaceuticals be established in order to assure universal access to medically necessary drugs, and that Canada's health care system be protected from international trade agreements, as we just heard.

Finally, we recommend that the twenty-year patents, which allow pharmaceutical giants monopoly control of drugs, be drastically reduced, and preferably ended, as soon as possible.

Those are some of our main comments. I guess my five minutes are up, aren't they?

Á (1150)

The Chair: We hope we can get at some of your other points through the questioning.

Ms. Mary Boyd: Yes, and they are written for the committee too.

The Chair: Good. Thank you very much.

We'll now move on to the Canadian Mental Health Association—I think it's the Nova Scotia division—and we have the executive director, Carol Tooton.

Ms. Tooton.

Ms. Carol Tooton (Executive Director, Nova Scotia Division, Canadian Mental Health Association): Thank you very much.

You were expecting Jean Hughes this morning. She was unable to attend, so I am filling in for her. I also have with me Claudette Gaudet, who is going to share this time slot with me. I believe you all received our brief beforehand, and I've also given speaker's notes as well for the presentation this morning.

Thank you very much for this opportunity to address the committee this morning. CMHA could address a number of issues, but we have decided to focus on two: issues associated with consumer access to drugs, and also the issues associated with monitoring adverse effects and prescribing practices.

For many of the millions of Canadians suffering from mental illnesses, drugs play a critical role in their recovery, helping them to function as valuable members of Canadian society. However, for many, such as the working poor or those who are homeless, accessing drugs is almost impossible because of the high cost. For others, access to prescriptions means being a slave to welfare, forcing them to remain in the system for fear of losing their medical benefits.

Also, despite advances in psychotropic medications, side effects are still a serious problem for many people, who end up abandoning their medications, choosing the symptoms of the illness over the devastating impacts of the drugs.

With advances in scientific research and the discovery of more effective and tolerable medications, evidence now indicates that recovery from mental illness is possible. Individuals can regain their rightful place in communities and lead productive lives. At the same time, there can be negative impacts to the use of medically necessary drugs that may not be known at the beginning of treatment and that can place critical barriers on the road to recovery. These negative impacts can have devastating consequences in all aspects of daily living.

We agree that access to prescription drugs is a medical necessity for the majority of people with serious mental illness. However, given that the costs of such drugs are not covered under the Canada Health Act, mental health consumers do not have coverage for prescription drugs when prescribed outside of hospitals. The result is that many consumers are unable to stay on medication when discharged into the community, leading to a return to hospital and being caught in the revolving-door syndrome.

An estimated three million Canadians do not have any drug coverage, and an additional three million do not have adequate coverage because of high deductibles and co-payments. Psychiatric medications are expensive. Mental health consumers tend to be among Canada's poorest citizens, and most depend on provincial social assistance plans for drug coverage.

The life of a mental health consumer on social assistance is a tragic game. On the one hand, while they have access to the medically necessary drugs at no personal cost, they must stay on social assistance and not seek employment. On the other hand, if they enter the work force, they are at risk of being denied employment health benefits, either because of their employment status being part-time or casual or because they have a pre-existing medical condition.

Even programs that require up-front payment with later reimbursement are difficult because of the costs of the medication.

Severe mental health disabilities pervade every aspect of daily living. They are periodic, cyclical, and long-term in nature and do not fit in to the rigorous format of social assistance policies, and the treatment is also as described; yet people with mental disabilities are often initially denied benefits.

As well, the poor wages generally accorded this population cannot begin to cover the cost of drugs or other treatments, often in excess of several hundreds of dollars per month, which sometimes are required for years.

Those who are not eligible for social assistance because they lack a fixed address—citizens who are homeless—have significant needs. This is particularly true for those with mental disorders. A recent study found that up to two-thirds of the homeless population have a lifetime diagnosis of a mental illness.

The Chair: Excuse me, Ms. Tooton, you've used up all your time, so we have to stop you if we want to hear from Ms. Gaudet at all.

Á (1155)

Ms. Claudette Gaudet (Consumer, Canadian Mental Health Association): Good morning. My name is Claudette Gaudet. I've been a consumer of the mental health care system for approximately 30 years, during which time I was the only one of seven children to successfully complete university, and since graduation I have been employed as the vice-president, corporate services, for a privately owned engineering company, both as a partner and on the board of directors; the manager of a very busy plastic surgery practice; and assistant registrar, and previously admissions assistant, at a local university.

You cannot imagine the devastation I felt when six years ago I was forced due to ill health to leave the workplace—the one safe place I had always known, the glue that had held me together emotionally and mentally for so long.

As you will note in the letter I submitted to you previously through the Canadian Mental Health Association, I recently experienced severe withdrawal symptoms from coming off a psychotropic medication, and, angry over the circumstances I found myself in, I reached out to the CMHA for guidance as to how to make best use of the circumstances.

Despite having a health benefit plan, I have spent significant funds on drugs, both prescribed and over-the-counter, to manage my psychiatric disorder and the side effects, while living on a disability income. I've experienced inferior prescribing and monitoring practices among psychiatrists, pharmacists, and general practitioners that rendered me, a university graduate with distinction, a virtual zombie for three years, incapable of making decisions around even the most basic of daily activities and the simple act of reading a novel an immense struggle.

I was never appropriately informed by anyone in the medical system about medication side effects and treatment options, and consequently I had to do my own research and teach myself how to ask key questions before consenting to take medication or to undergo medical treatment.

Regrettably, and adding further to my distress, in the midst of this severe health crisis, the health care system not only failed me but abandoned me. How fortunate I am to have had the loving support of family, friends, and non-traditional therapists in trying to resolve what has turned out to be the most significant medical crisis I have ever faced.

I want to thank you for the opportunity to speak and to present the document I submitted earlier regarding my recent experiences. Thank you.

The Chair: Thank you, Ms. Gaudet.

We'll now move to the second part of our meeting this morning, which is the question and answer session by the members of Parliament. Looking at the clock, we have 35 minutes, so I'm going to ask my colleagues to be as precise as possible so that we have some time for Mr. Barrette.

Mr. Merrifield.

Mr. Rob Merrifield: I won't take terribly long.

Claudette, I'd like to follow up a little bit on your experience with the health care system and your mental illness.

It's usually mental illness, in most of the provinces, that we're struggling with being able to deal with in an effective way; it's not unique to any place in Canada. You allude to the problem we had a number of testimonies this morning about, dealing with the whole area of pharmaceuticals and whether they are causing perhaps more harm than good at times because we're not aware of the adverse reactions to them and their adverse effects.

I'm wondering, in light of your experience—and I don't know, that's why I'm asking the question—are you familiar with the therapy the Centre for Emotions and Health is providing? Is it something you have looked into?

Ms. Claudette Gaudet: I'm sorry, the Centre for...? No.

Mr. Rob Merrifield: This is what I was looking for this morning, and the awareness of this seems to be very limited. They take people completely off medication over a 20-week period. The success rate, according to this individual, is 80%.

I know you lobbied us to open up more access to medication. There's a valid reason for that, and I understand where it's coming from. This committee is looking at the problems of medication as well, and we fear going down the road of easier access if we don't deal with the abuse problem first.

I wonder if there are any comments from the panel on that perspective.

Mr. Ian Johnson: Thank you, Madam Chairperson.

We're not here to deny the problems you've talked about, or our friend from CMHA, but we think the solution, or least a step in that direction, is really to move to a national program.

One of the problems we have with the patchwork--and you may have seen some of the statistics we referred to in terms of Nova Scotia--is the fact that there are lots of gaps, there is duplication, and there are problems.

So if we're really serious in addressing both the need for prescription drugs and problems that may occur from them, we need a national program to deal with it properly. I hope you would take that from our presentation today.

Ms. Carol Tooton: Just to add to that, if I may, traditionally there are a number of people with mental health issues who often look to non-traditional approaches to deal with their illness, but I don't think there has been a lot of support for that within what we call the formal mental health system.

Mr. Rob Merrifield: Thank you.

The Chair: Thank you.

Mr. Ménard.

Â (1200)

[Translation]

Mr. Réal Ménard: Thank you, Madam Chair. I have only one question, given our time constraints.

I'm a Quebec MP. In 1995, the government preceding the one headed by Jean Charest introduced a drug insurance scheme. Quebeckers pay a reasonable premium for that insurance. In its first year of existence, the scheme ran into financial problems and premium levels were revised because of drug costs.

I'm trying to reconcile your testimony, which draws its inspiration largely from the Romanow Report. The federal government cannot be the party that reimburses drug costs, except for aboriginals and military personnel, because this is a provincial area of responsibility. In your opinion, what role could the federal government take on in terms of introducing a drug insurance regime, given that it's clear the various provinces will have to reimburse the costs incurred? I don't know who wants to field that question? Perhaps Mr. Johnson would care to venture a response.

[English]

Mr. Ian Johnson: Thank you for the question. It is an important one, obviously.

In terms of a federal or national-provincial program--and I recognize the differences with Quebec--we need to move in that direction. Clearly, as the National Forum on Health reported, the costs are there now, whether we do it through the public system or the present system of mixed public-private. We need to move in that direction in order to clarify. We need the federal role in terms of leadership and putting in place the steps towards a national program.

We have the Romanow report recommendations, which you're familiar with, and the earlier national forum recommendations, which certainly suggest there are steps to take to move to that, which would include an important role federally in terms of taking leadership, bringing people together, and setting up the national health council, which we think is important as part of this. So there are steps you have already, that you're aware of, that will help bring this together.

It does mean negotiation, but maybe that's where the national health council can play an important role.

[Translation]

Mr. Réal Ménard: You're not answering the question. Let's begin by assuming that the federal government must assume leadership in this area, something that I disagree with as an MP. What role do you see the federal government playing? Would you like to see transfer payments to the provinces increased? Mention is made in the Romanow Report of an emergency drug fund. However, the report doesn't say anything about operationalization. The federal government wants to intervene any way it can in the health field. Tomorrow, MPs will be voting on Bill C-13 which attempts to tell the provinces how to deal with reproductive technologies and to tell health care professionals how to implant embryos or provide fertility treatments. The government cannot use health care as way to conduct nation-building exercises. I hope my colleagues agree with me on that score. If the federal government is to get involved in covering drug costs, you need to suggest to us how this arrangement would work. If you simply want the federal government to increase transfer payments, I have no problem with that. However, if you think the federal government should be responsible for the drug insurance scheme, then I can't go along with that.

[English]

The Chair: Ms. Tooton.

Ms. Carol Tooton: I echo what Ian has said, in that we look to the federal government for the leadership. If that means additional dollars added to ensure that the direction is followed, yes.

With many issues our national organization has been lobbying for some time for a national strategy on mental illness. We're one of the few countries in the world that doesn't have one. In that, I'm sure the drug costs would be covered. It's in that kind of issue, I think, that the federal government plays a huge role.

The other thing is we need to have a change in thinking. Just pouring more and more money into the health care system isn't solving the problem. In our paper this morning we were met with the announcement that overtime costs weren't going to be paid by the largest health district here in Nova Scotia; that if people are sick they're not going to be replaced at work that day because they've overspent their budget already for this year. If we give them another $10 million, is that going to solve the problem? I don't think so. We need to change our way of thinking in how we deal with these issues.

From our organization's perspective, we mentioned the employment issue. Many people with mental health issues could go back to work if they were able to hang on to their drug card. That's going to be a heck of a lot less expensive than if they were on social assistance full-time.

I'll stop there, because someone else—

The Chair: Thank you, Ms. Tooton.

I think Ms. Summers wanted to comment on one of these issues.

Ms. Maureen Summers: Thank you. I'm realizing you have to jump in really quickly here.

I wanted to address your question because I think it's phenomenally important that the federal level of this country take a stand and play a role. We need to have national standards for a pharmacare program for access to pharmaceuticals that are required by patients across this country.

An individual with a diagnosis of cancer in Nova Scotia—a similar diagnosis compared with another province in western Canada—will have a different outcome. Surviving cancer or having an adequate cancer journey cannot be dependent on geography or income level. There have to be standards set that are applicable across this country, and there needs to be equal access to the treatments and medications that a cancer patient or other Canadians living in this country have experienced, so that a patient can be appropriately treated and have an adequate quality of life.

Â (1205)

The Chair: Thank you, Ms. Summers.

Ms. Brown.

Ms. Peggy Brown: Yes, I'd like to make a comment.

Speaking about persons with disabilities, good coverage is a critical thing, because if they don't get enough in social assistance to cover their drug coverage, they take it from their budget allowance to cover their drugs. This means they don't have the proper food to provide themselves for that month.

The Chair: Ms. Boyd.

Ms. Mary Boyd: You might have heard us say that none of the Atlantic provinces has a universal drug plan. We're certainly below the national average in a number of ways, and we are quite interested in seeing that the federal government play its appropriate role in relation to pharmaceuticals and in relation to health in general.

There has been an enormous downloading of federal government responsibility onto the provinces, and a cutting back of money, which has really harmed us in many ways. There's a matter of political will there, because there's a surplus of $7 billion this year. In fact, it's probably more than that, because we know those surpluses are usually understated.

None of that is going into health or into any kind of social program that was cut back and taken away from the people of Canada; it's going against the deficit. But there are other ways to care for the deficit. First of all, taking the money from those social programs but then refusing to put it back is wrong. The federal government has to increase its contribution to health care in this country; it's a recognized thing. The surplus is one place to start, because this is very urgent. Our provinces need help in this. We just can't do it alone.

If we had time we could tell you about the cases we come up against—people who really need catastrophic drugs and drug help and are not getting it, and the suffering that goes with that.

The other thing I wanted to say, in conclusion, is that there's a very dangerous kind of attitude in Canada. When people reach a certain age, because of these costs we're always harping on—we're saying we can't afford our hospitals, we don't have enough staff, we can't afford drugs. When people with certain illnesses or people of a certain age get into our hospitals, I'm afraid they are let go. There's a kind of phrase, “quality of life”, that goes around.

Ideas, a couple of years ago, had a feature program on this and gave many warnings about slipping into this attitude towards quality of life, which was very much what happened in Germany, and warned to look at the dignity of the person and give each person every possibility to live, no matter what their illness, no matter what their age. I think this business of saying we have no money is feeding into that kind of thing. I have witnessed, and other people have, patients who have been really left to die, when in fact we don't know what would have happened if they had been given the appropriate medication and other support.

Mr. Réal Ménard: Regardless of who is in the government, you're right.

The Chair: Thank you, Mr. Ménard.

Ms. Bennett.

Ms. Carolyn Bennett: Thank you very much.

Maybe we'll start with the Cancer Society. When the Romanow commission came out, a lot of people said the catastrophic drug recommendation was really only for Atlantic Canada because almost every other province already has one. Is that your experience in the Cancer Society?

Ms. Maureen Summers: I can't speak for the other provinces. I know they have systems in place that are better than what we experience in Nova Scotia; however, I don't know that those systems can handle catastrophic drug coverage, as the pharmaceuticals are changing and as drug prescribing methods are changing.

In looking at Atlantic Canada--and the information I have is specific to Nova Scotia--we know that 25% of Nova Scotians do not have coverage of any kind. We also know that 50% of Nova Scotians earn an income under $20,000 a year. This has major implications for the tax revenue for the province and its ability to support its citizens. However, I don't think Atlantic Canadians are any less Canadian than other Canadians. The role of the federal government in this situation, in looking at access to appropriate treatments and medications, is to set those standards under which new programs can be developed, or revise programs so that catastrophic drugs are accessible and that catastrophic situations can be ameliorated.

Â (1210)

Ms. Carolyn Bennett: British Columbia has much better cancer outcomes than any other province. Do you see that as screening and follow-up, or is it access to drugs? Do you have any experience of people being admitted to hospital here in order to get their drugs?

Ms. Maureen Summers: I can't speak to the B.C. experience in its entirety. I would imagine that the situation of better outcomes is due to the comprehensive approach, that there are higher rates of screening, that disease is potentially treated differently, and that there is better access to treatments.

We are very aware of cancer patients who approach their physicians to admit them to hospital so that they can get the drug coverage they need in a facility where it will be covered, yes. We hear that a great many times throughout the year.

Ms. Carolyn Bennett: Thank you very much.

In terms of the Mental Health Association, I think I need to follow up on Rob Merrifield's question because I think you need to explain the difference between what was offered by the brief psychotherapy presentation this morning in terms of anxiety, depression, and personality disorders and what you are talking about in terms of severe mental illness and the number of people with severe mental illness who would be better off, off medication.

Ms. Carol Tooton: Not having heard the presentation this morning, and I must admit, having worked here in Nova Scotia for 10 years for CMHA, I do not know about the facility you're talking about.

The Chair: [Inaudible—Editor]...community and the people on the ground. The man who presented actually said to us that one of his problems is he has no money for, as he called it, marketing--what I call public relations and alerting the network.

Sorry, Carolyn.

Ms. Carolyn Bennett: In terms of brief psychotherapy, it applies to anxiety, depression, and personality disorders. It does not apply to schizophrenia and some of the more severe mental illnesses. I think I missed the point of Ms. Gaudet's presentation. Are you on medication now?

Ms. Claudette Gaudet: Yes.

Because I'm still experiencing side effects, I would absolutely prefer not to have to be on medication. I've had to go on more medication as a result of the withdrawal from this other drug.

Ms. Carolyn Bennett: But your point was that your treatment over time was suboptimal in terms of you being--

Ms. Claudette Gaudet:

It was, and certainly there were side effects. It's almost as if people think it's a side effect, just a side effect, or it's only whatever. But when the symptoms become...and it was only in coming off them, this medication, that I became aware of how greatly affected my physical and my mental health had been by virtue of being on the medication. So unless someone is paying attention when I say I have this thing happening and that thing happening and the other thing happening, and no one twigs to the fact that these are all side effects of this medication and that medication, and when they give you another drug to help you with that side effect and another drug to help you with that side effect, you end up in a situation where you're taking lots of medication, all of which have side effects, so that you don't know any more what is your basic illness. I'd like to get back to a sense of knowing who I really am and at what state is my physical and mental health.

Ms. Carolyn Bennett: And did you feel that there was coordination between the various health professionals, the pharmacists, your family doctor, or...?

Ms. Claudette Gaudet: No. I feel very much like I was hung out to dry. And when I told people I was experiencing side effects, everyone was in favour of my coming off the medication, but I wasn't given the information I needed. It turns out everybody in the world was aware, it seems, of the potential problems with this particular medication that I wasn't given the warning about. When I started to come in and say, I'm experiencing these problems with withdrawal, I didn't have intervention right when I needed it. Three and a half months later I still haven't had a satisfactory resolution. I still haven't gotten the support I need from the medical community to satisfactorily resolve this for me. In fact, I've been told, casually, we need to increase this, that, or the other. But no one is speaking with anyone else. My symptoms are not taken seriously, and I feel abandoned. Absolutely.

It was interesting hearing the pharmacist speak this morning. I go into the pharmacist's and there are eight people in front of me and they have a two-hour backlog. I don't know when they have the time to spend time to speak with people coming in with prescriptions about side effects. And the information we are given about our medication is minimal.

If you go and do the research, as I did, sometimes before and sometimes later, you find out a lot more information about the more obscure side effects, many of which I've been a victim of over time, that you wouldn't otherwise know about. I think family doctors are not necessarily aware of these, and even the prescribing specialists. They have the information. You say specifically that you have a medical problem. For example, I have an elevated intraocular pressure, probably as a result of being on these medications. Last week, two separate doctors recommended that I take the drug that's contraindicated specifically when you have that medical condition. So people are dropping the ball right, left, and centre, and I felt like I was falling between all of the cracks.

Â (1215)

Ms. Carolyn Bennett: Did you hear Dr. Zitner's presentation in terms of how informatics...? I think a lot of us feel that with BlackBerry prescribing, a lot of those things could be eliminated very quickly in terms of the patient safety part of that.

Ms. Claudette Gaudet: Yes. I considered myself, and certainly my family and friends considered me, to be at considerable risk these last many months. I sit here calmly today, but I was literally shaking and crying in terror. I'm not just talking about a little bit of panic, I'm talking about terror, and that was allowed to continue despite my cries for help.

The Chair: Thank you, Ms. Bennett.

Mr. Robinson.

Mr. Svend Robinson: I do want to thank you, Ms. Gaudet, for your courage in sharing this morning with the committee some of your experiences, particularly given some of the stigmas that, unfortunately, still exist in the mental health field. It's very brave of you to be here, and I can assure you that we take very seriously what you're saying.

On a personal note, I want to congratulate you on your 50th birthday, which you just celebrated recently, having passed that milestone a couple of years ago myself.

I do want to thank all of the witnesses for your evidence this morning and to voice a little bit of frustration. As the folks from the Nova Scotia Citizens Health Care Network and Mary Boyd and others have pointed out eloquently, we have recommendations on how to deal with a lot of these problems. The Romanow commission held hearings across the country, just like we're doing, and made a number of very concrete and specific recommendations, and here we are again saying to you, what do you think we should be doing about pharmaceutical drugs? Get on with it, frankly. I would say get on with it.

There are a number of recommendations, and I want to say I fully agree with the points you're making that reinforce the recommendations of the Romanow commission, including the importance of health counselling, by the way. God knows where that will ultimately end up and how it will look once the premiers are finished with it.

I also have to say I find there's something tragic and obscene that we still hear the stories from the Canadian Cancer Society, and from Peggy Brown and others, of people having to choose between food or decent heating and drugs in a country like Canada. It's obscene that this should be happening, and then we hear about a $7 billion surplus. There's something wrong with that picture.

So thank you for your recommendations, and I must say I was particularly pleased to hear the recommendation from the health care network about the importance of possibly even considering a national drug industry. I think it's long overdue that we've said maybe it's time in a country like Canada that we had a publicly owned industry committed to health and not just to the bottom line and corporate profits, and that research is being done, as Mary Boyd said, that is publicly supported, the kind of research that led to the discovery of insulin, for example, by Drs. Banting and Best. And when Dr. Best was asked about patenting insulin, he said, “I'd no more patent insulin than I'd patent the sun”. Maybe we need that kind of approach as opposed to trying to figure out how much money we can make out of this.

I have a couple of very brief questions. We heard earlier from Dr. Zitner the suggestion that there should be a deductible with catastrophic drug coverage. I think we should just move a lot further than catastrophic drug coverage. I'm a bit troubled by this notion that if you're not facing a medical catastrophe, then you're on your own. I think drugs should be considered part of the health care system generally.

Tommy Douglas said that a long time ago, but I'd like to hear one of you respond to the suggestion. Here's what he said: “People who spend their own money are more likely to be cautious in the use of health care resources and except for the very poor are not harmed. I support first dollar coverage.”

Do you have any comments on that particular suggestion?

Â (1220)

Ms. Peggy Brown: As a disabled person I have a low income, and that's not a very nice thing to say, because you watch every penny you spend. As my husband is on a seniors' program and I am on a disabled program, I'm watching my dollars more than ever.

Mr. Svend Robinson: As my last question, could I ask the representative from the Canadian Cancer Society--and again, thanks for your brief--do you have any recommendations with respect to the issue of the control of drug prices? I'm thinking here of some of the recommendations that some of the other witnesses made around evergreening, the practice of evergreening, patent legislation, and so on. We used to have some of the cheapest drugs in Canada with compulsory licensing.

One of the concerns I've raised and some others.... And I'm not sure if you get money from the pharmaceutical industry here in Nova Scotia, but some wings of the Cancer Society do, as you probably know. When we bring in a national pharmacare plan, do you have any views on the importance of not just making it a gravy train for pharmaceutical companies but at the same time making sure we deal with some of the other issues that will keep the cost down?

Ms. Maureen Summers: Yes, I think the two really have to be looked at in tandem. I gave the example earlier of Lupron, which costs $6,000 annually. There are other cancer drugs that can cost upwards of $25,000 or $30,000 a year.

You can't have escalating drug costs and not look at the evergreening, at the patent laws, at the 20-year patent. In 20 years, the whole mix of what a formulary would look like is going to be so substantially different because of new research and new developments that it almost seems ridiculous, frankly, and I think the committee and the government do need to look at the combination, as outlined by Romanow, of formulary, patent laws, and equitable access.

Mr. Svend Robinson: And no direct consumer advertising? I take it the witnesses here would agree with that.

I'm sorry, the microphones don't pick up nodding.

Mr. Ian Johnson: Yes, we certainly do agree.

Sorry, I thought at least you wanted an acknowledgement. But you're right, absolutely. We have very serious concerns about that.

Mr. Svend Robinson: Thank you.

The Chair: Thank you, Mr. Robinson.

Mr. Barrette.

[Translation]

Mr. Gilbert Barrette: Thank you. Like Mr. Ménard, I too would like to discuss federal and provincial areas of responsibility. Would you like our committee to recommend that the federal government bring in a national drug program?

Let's look at what such a program would entail, if certain illnesses or drugs had to be identified, and how costs would be controlled. If a no-cost national program is introduced—I'm not talking here about emergency drugs to treat cancer or other such diseases—we run the risk of people abusing the program. We've all seen cases of that happening. How would we control this? What role would the provinces play? What choices would be available? Surely you can exercise a direct influence on your politicians, senior officials and decision-makers. The province will have to make some choices, decide which drugs will or will not be covered under the scheme based on the needs expressed by the various associations and based on the various problems or new illnesses that may emerge.

Â (1225)

[English]

Mr. Ian Johnson: Thank you for your question. It's a good point.

What we've tried to outline, going back even to the National Forum on Health, is that it should be a staged approach. We're not here to say it all has to happen at once. There are stages to move towards a proper national program, but start with, as Mr. Robinson has pointed out, dealing with the patent legislation.

The most serious problem we're facing--and we said it at the time, and I was part of the debate in 1987--is moving away from compulsory licensing. We're here to tell you very clearly that we can't move ahead with a national program of public funding if something isn't done to end or at least reduce the patent protection. Otherwise, it's a very expensive move forward.

But clearly there are steps, and again I'll go back to Romanow's outline giving us six very clear recommendations to move ahead in terms of controlling cost.

We need a new national agency to deal with drug costs.

On the provincial role, absolutely, we're not here to say there shouldn't be a provincial role. A national formulary, again a Romanow recommendation, would obviously include provincial recommendations.

We have in the Atlantic region now an Atlantic drug review process. That could be a stepping stone to a national formulary.

So there are clearly, as Mr. Robinson said, steps that have already been outlined, but we really urge you to take action on the patent protection and the practice of evergreening.

The Chair: Thank you, Mr. Johnson.

Would anyone else like to comment?

Ms. Maureen Summers:

We need to have federal-provincial-territorial collaboration and cooperation. From our perspective, the areas of quality assurance, of standards, of critical practice guidelines, the formulary that's evidence-based, can all be developed to frame a situation so that any Canadian with a diagnosis of a chronic disease—in our case our concern is cancer—can have the care and treatment that any other Canadian is afforded.

I think the presentations and the work that was done by the Romanow commission, that was done by Kirby going across Canada—those are all of the solutions. We've made presentations, and as has been noted, there is a lot of work; there are lots of recommendations. Romanow outlines the key areas that need to be addressed. We would really encourage work on federal-provincial-territorial cooperation and collaboration and the development of standards across all areas.

The Chair: Thank you, Mr. Barrette.

Ms. Boyd, do you want a last word?

Ms. Mary Boyd: Sometimes we really have to look at where the so-called abuses are coming from. I think in a lot of cases it's not the patient who is doing the abusing; it's the way drugs are prescribed. I think a big amount of the abuse comes from doctors prescribing open-handedly and being influenced too much by salesmen from the pharmaceutical companies, who pay for their conventions and bring them gifts.

There's a lot of corruption in the whole way medicine is practised in this country. The kinds of things that happen around drugs would not be acceptable in any other professional circumstances. They need to be looked at and named, because the public is totally shocked once they become aware of these practices.

When doctors are rewarded for prescribing the drugs of certain companies and so on, this is very problematic. I'm happy to see that some doctors are very careful now and don't prescribe easily. But I was visiting a patient in a hospital recently; he was on something like 36 drugs. He wasn't a low-income person. By the time I stopped talking to him he had cut them down to nine, by going through the process of elimination himself in the hospital with help.

Now, how do those circumstances happen? To me, that's where the abuse takes place, and not at the level of the patient. It's at that level that there has to be study and scrutiny. And I really believe that when a new drug comes on stream, a scientist from Health Canada should be the one who explains that drug to the doctors, not the salespeople from the pharmaceutical companies. If we're going to do this right, we have to acknowledge there's an area there that has to be done away with, because it's.... Words fail me, actually, to describe what I think it is, but as I said, it would not happen in any other profession or sector.

Â (1230)

The Chair: Thank you, Ms. Boyd.

On behalf of all the members of the committee, I want to thank you so much for putting your presentations together and coming to give us your thoughts on the subject we're studying.

At this point I will alert the members of the committee that we just have an hour for lunch.

Thank you very much to all the witnesses. They were excellent presentations.

We'll now adjourn for lunch hour.