PACC Committee Meeting

STANDING COMMITTEE ON PUBLIC ACCOUNTS

COMITÉ PERMANENT DES COMPTES PUBLICS

EVIDENCE

[Recorded by Electronic Apparatus]

Tuesday, June 5, 2001

• 0939

[English]

The Chair (Mr. John Williams (St. Albert, Canadian Alliance)): Good morning, everybody.

Mr. Mac Harb (Ottawa Centre, Lib.): Good morning, Mr. Williams.

The Chair: Good morning, Mr. Harb.

Everybody is bright and cheerful this early Tuesday morning.

Pursuant to Standing Order 108(3)(e), we are considering chapter 15, “Health Canada—First Nations Health: Follow-up”, of the October 2000 Report of the Auditor General of Canada.

• 0940

We are departing from our normal course, where we normally have senior governmental officials as witnesses. This morning we are joined by Ms. Lorraine Stonechild from Saskatoon, Saskatchewan. We welcome you as an individual here this morning to hear your story. We understand that you have lost your brother and your son, and on behalf of the committee, we first want to extend our deepest sympathy to you. We would also like to hear your story, and we thank you so much for coming along this morning.

Don't be intimidated by the people around the room. We're just ordinary folk trying to run this country the best we can. When we find problems, we try to fix them. We want to try to help you and your people. So we thank you for coming along this morning.

Our other witnesses are from Health Canada: Mr. Ian Potter, assistant deputy minister, first nations and Inuit health branch; Dr. Peter Cooney, acting director general, non-insured health benefits; and Mr. Harry Hodes, assistant regional director, Alberta-Northwest Territories, first nations and Inuit health branch. From the Office of the Auditor General we have Mr. Ronnie Campbell, principal, audit operations branch, and Mr. Glenn Wheeler, director of audit operations branch.

This morning I think we'll start with an opening statement by the Auditor General's office, followed by an opening statement by Health Canada. We will not of course have an opening statement from Ms. Stonechild, but we'll have a dialogue with her.

She will make a short statement.

Mr. Campbell, we'll start with you.

Mr. Ronnie Campbell (Principal, Audit Operations Branch, Office of the Auditor General of Canada): Mr. Chairman, thank you for the opportunity to discuss further some of the results of our audit, “Health Canada—First Nations Health: Follow-up”, as reported in chapter 15 of the 2000 report tabled in October. I have with me Mr. Glenn Wheeler, director of audit operations.

We also reported on Health Canada's management of first nations health programs in 1993 and 1997. The issues in our most recent report are not new. After each audit the department has agreed to our recommendations and undertaken to fix the problems identified.

As noted in our most recent report, we are concerned that the department has not made sufficient progress to fix many of the problems identified. We remain deeply concerned that the program allows individuals to access excessively high levels of prescription drugs.

[Translation]

Mr. Chairman, the weaknesses we observed have important consequences, and it is imperative that corrective action be taken in a timely manner.

Our 2000 Report contained observations on both contribution and transfer agreements, as well as several aspects of Non-Insured Health Benefits. Following from the discussion at our last hearing on April 5, we would like to briefly address some points related to the issue of prescription drugs. We would, however, be pleased to answer any questions that the committee may have on any of the issues covered in the chapter.

It is important to distinguish between the different systems that Health Canada has in place, what they do, and what they can be expected to achieve.

[English]

First, the department has implemented control on prescription drug use through a point-of-service system. This system provides warnings to pharmacists prior to prescriptions being filled. These warnings are intended to highlight potential duplications and drug-to-drug interaction.

Second, the department can retrospectively monitor drug use on an aggregate basis, tracking the use of different types of drugs by geographic area. This can identify trends in use and help to highlight prescribing practices by physicians.

Third, the department can retrospectively monitor drug use by individual patient. We noted that the department had some early success when intervening on the basis of such analysis. However, our audit found that this intervention had been terminated.

Finally, the department has various controls over payments. These include system edits and audits of providers.

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Mr. Chairman, in discussing Health Canada's responses to our recommendations, it may be helpful to maintain these distinctions between the different activities.

Overall, Health Canada's action in response to our 1997 audit has not adequately addressed our observations and recommendations, or those of your committee. Continued and sustained effort is needed to ensure that all the recommendations are implemented.

Mr. Chairman, that concludes my opening statement. We'd be pleased to answer your committee's questions.

The Chair: Thank you, Mr. Campbell.

Now we'll turn to you, Mr. Potter, for a short statement, please.

Mr. Ian Potter (Assistant Deputy Minister, First Nations and Inuit Health Branch, Health Canada): Thank you, Mr. Chairman.

I have tabled an additional document with the committee, which I trust members may have a copy of. It strives to address some of the questions you had asked the last time I was here on April 5.

We are also in the process of translating the material you had asked for at that time, and as soon as the translations are complete we will forward that material to the committee.

The intent of my discussion, or opening statement, today is to address a few items. One is the extent of the problem of potential prescription drug misuse in the non-insured health benefits program, noting some of the activity Health Canada has done to address it, the roles of other agencies and bodies we work with, the problem of prescription drug use as it relates to privacy, and what are our future plans.

The prescription drug misuse is a general problem and the full extent of it is not known. It's not a problem that is just a problem for our program or for first nations and Inuit people. Health Canada has addressed the problem, over a number of years, through education of the public and professionals, introduction of controls in the non-insured health benefit program, and in cooperation with the provinces and provincial associations.

I've provided a comparison of our program's use of codeine-containing drugs and benzodiazepine, which are the most common drugs that are misused.... If you look at the chart on page 4 of my brief, it illustrates that the beneficiaries of the non-insured health benefit program use drugs of these types relatively the same as others using public plans do.

We're using a study that was conducted in 2000, and it provided us with information with respect to the British Columbia public plan. There you can see that in the non-insured health benefits program the use of codeine-containing drugs is about 991 prescriptions per 1,000 beneficiaries, as opposed to the B.C. public plan, which is 1,021 prescriptions. Similar types of numbers exist for benzodiazepine.

Our program covers over 700,000 eligible beneficiaries, and less than 0.05% of these beneficiaries exceed the recommended maximum dose of these drugs in a three-month period. The point is this is a small number of people, but at the same time it's an issue of importance for those people. I wouldn't want to leave the impression that because of the small numbers relative to the total covered beneficiaries we aren't concerned about the impact on individuals.

I provided on page 6 a chart that shows over time the changes in the use of benzodiazepine and codeine-containing drugs. As the trends on this chart show, the prescriptions for codeine-containing drugs and benzodiazepine have changed little over the five-year period. The growth rates are about 2.9% per year for codeine and about 5% for benzodiazepine. This is in relationship to a growth in population of about 2.5%. The numbers of clients are increasing by about half, so you're getting, with respect to codeine, almost no increase and about a 2% per capita increase for benzodiazepine.

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[Translation]

What are we doing? Health Canada deals with prescription drug misuse in various ways. We have put in place an electronic system to warn pharmacists about duplicate prescriptions, and we are renewing the process more frequently. We provide aggregate information to regulatory bodies. We do an ongoing review of the Drug Benefit List, and we de-list, where appropriate, certain prescription drugs that are misused.

The community health programs and facilities have expertise in treating prescription drug addition. We have introduced education and information programs on the appropriate use of prescription drugs and the prevention of drug misuse for First Nations and Inuit beneficiaries. We have introduced a system to monitor drug use with the provincial authorities, the industry, physicians and pharmacists.

[English]

Since the tragic death of Darcy Ironchild in 2000, Health Canada has added enhancements to its system of drug utilization review. Chief among them is a closer monitoring of pharmacists who override drug utilization messages when claims are submitted for payment and the setting of maximum allowable quantities over which prior approval is needed.

The system for dispensing prescription drugs to non-insured health benefits is complex. It involves the roles of patients, physicians, pharmacists, the regulatory bodies such as the College of Physicians and Surgeons and the College of Pharmacists, and the public and private payers of plans.

The non-insured health benefits program is the payer of the benefits. It is not a regulator of the physicians or pharmacists. We have no authority to act as a regulatory agency.

The last time I was here the committee asked for the numbers of referrals to regulatory agencies. I have provided that information on page 12, which indicates that since 1996, 36 pharmacists and 81 physicians have been referred to regulatory bodies, and actions taken range from withdrawal of billing privileges to a pharmacist, to criminal convictions.

It's important, as we develop our policy and manage the non-insured health benefits program, to balance the rights of the 700,000 people we cover with the needs of the small number of people who are subject to possible abuse of prescription drugs. This is an area where we're working to try to strike the proper balance.

I'd like to quote a recent statement from the Privacy Commissioner of Canada, George Radwanski, who underlined the importance of privacy. He said that personal health information belongs to the individual, not to anyone else, and the individual has a right to determine who gets it and for what purposes.

The privacy laws demand that information about clients not be disclosed without the client's consent. As I explained the last time we were here, we were working with the Assembly of First Nations and with the Inuit Tapirisat of Canada, to put in place a system of consent that would allow us to be able to use the personal information we collect to deal with situations when there is possible abuse of prescription drugs.

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Looking to the future, we are introducing a number of things. We are extending the list of medications with maximum allowable doses. This is a system we've put in place recently that puts a limit on how much of a particular drug a patient can receive. If they're prescribed more than that limit, a flag goes up in our system, and it requires an intervention from the physician to override those limits.

We are also continuing discussions with first nations and Inuit to clarify the consent issue, and we hope we will be able to begin to put in place a system in the fall to address the consent situation. We are also increasing prevention activities, through strengthened education and promotion programs.

Thank you very much, Mr. Chair.

The Chair: Thank you, Mr. Potter. Now we'll turn to Ms. Stonechild. I understand you're going to give us an opening statement. We appreciate that. Thank you.

Ms. B. Lorraine Stonechild (Individual Presentation): I'm talking from a personal level here about my brother and my son and their deaths.

I have a hard time understanding why 300 prescriptions were written for my brother and no one monitored them or told anyone. I know the government had all this information in a database, and if this information had been shared, maybe he'd still be alive today. I made various phone calls to try to stop it, and no one was listening.

Right now, there are several people out there who are getting prescriptions—being double-doctored. I would like to see that stopped, and for first nations to heal and not rely on prescription drugs.

Another thing with codeine—I was just listening—is you can buy it over the counter. That's one of the biggest drugs that is abused. You can go to any pharmacy. I talk to people and they share information with me. When I talk to people, someone always tells me someone has died of a drug overdose in their family. This has to stop. We can't keep letting first nations people die through the carelessness of the government, doctors, and pharmacists. All information should be shared, so this doesn't continue.

I'm asking, please make these changes soon. I don't want to see any more people die. I want to see my grandchildren live a healthy life, without relying on any kinds of drugs to cover up their feelings, and be healthy. Please do something, I'm asking. Don't let this continue. I don't want to see my grandchildren going to doctors, who write out prescriptions for them. We need them to be healthy. We need to have healthy people. Thank you.

The Chair: We thank you very much, Mrs. Stonechild, for expressing to us how difficult it has been for you, how heartbroken you are, and the need for everyone in this country to have the opportunity to see their children and grandchildren grow up healthy and in a safe environment.

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We hope, by this meeting here today, we can start the ball rolling to try to provide the things you are asking for.

I'll now ask Mr. Bryden to start the questions, please.

Mr. John Bryden (Ancaster—Dundas—Flamborough—Aldershot, Lib.): Thank you, Mr. Chairman.

I just want to begin by saying that one of the reasons we're very anxious to hear this testimony from Mrs. Stonechild and others is because this committee has been aware of this problem for some time, and we're absolutely resolved to trying to find a solution to the problem as soon as possible. As Mr. Potter has said, we don't know how many people are affected, but we do know there are people who may be dying, actually, may be experiencing the same kind of abuse.

Mrs. Stonechild, let me begin by asking you whether you perceive this to be a problem that might particularly afflict aboriginals who are living in urban settings, rather than on reserves. Is this something that's maybe more typical for aboriginals in city settings?

Ms. Lorraine Stonechild: I think it's more typical in the urban setting because there's access to the doctors, pharmacists are right there, and people get together and share who is a good doctor and how they can get prescription drugs. One prescription leads to another, and pretty soon they're addicted. They shop around for doctors who will provide the prescription drugs. I see a lot of it in my daily life. I see it all over the place.

On the reserve, they don't have access to the doctors and pharmacists. They have to travel to the city to see any physician and go to any pharmacy to purchase any kind of drug.

Mr. John Bryden: Mr. Potter, you suggest that your studies indicate the number of people actually abusing the system is comparatively small. Does your study separate urban aboriginals and their use of the plan from aboriginals living on reserve?

Mr. Ian Potter: It doesn't, Mr. Bryden.

Mr. John Bryden: So you have no idea how extensive this problem might be in the urban setting, whether it's in my community of Hamilton, in Saskatoon, or anywhere else.

Mr. Ian Potter: I don't.

Mr. John Bryden: Let me go back to Mrs. Stonechild for a moment.

Mr. Potter suggested there was an effort to get some kind of consent agreement with the Assembly of First Nations. Will the Assembly of First Nations speak for aboriginals living in urban settings, in terms of whatever consent definition agreement it comes to with Health Canada? Will it make a difference?

Ms. Lorraine Stonechild: I think it will make a difference.

Mr. John Bryden: In what sense; what will people do?

Ms. Lorraine Stonechild: I think they'll work harder to do research to see how many first nations people are getting prescription drugs. With their help, it will be open. I feel it will do wonders. It will be a fantastic thing, if it happens.

Mr. John Bryden: Let me ask you another question, if I may, Mr. Chairman. There's a privacy issue here as well. I have just a hypothetical question to you, in the sense of the people you know in your immediate experience where you live, who may be experiencing or know people who are experiencing this problem of drug abuse, under the non-assured health benefits plan.

Would it be unreasonable for Health Canada to tie the beneficiaries under this plan to a disclosure agreement, whereby if they're going to access this plan for prescription and non-prescription drugs, they would sign a consent agreement that the identity information would be exchanged with other pharmacies, with other physicians? Would that be possible?

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I'm sorry, the question is probably needlessly complicated. Let me try it again. In your view, would people be willing to surrender a certain amount of their privacy in exchange for better oversight of who may be abusing the plan?

Ms. Lorraine Stonechild: I think there should be a consent form filled as soon as they go to the doctor, so that prescription drugs can be monitored. I know the Privacy Act plays a major role in prescription drugs, and I think everyone visiting a physician should consent, so that no one is hiding behind anything and it's open.

Mr. John Bryden: Not going into a great deal of detail, can you give us a sense of what happened with your family members? Did they move around getting prescriptions at various places?

Ms. Lorraine Stonechild: Yes.

Mr. John Bryden: Was it a doctor problem, or was it a pharmacy problem?

Ms. Lorraine Stonechild: It was a doctor problem, I believe, and they just moved around from doctor to doctor, whatever was easy. It takes time to track. All the computers weren't all doing their job, they weren't connected, so it was easy for my brother and my son to go to various pharmacies, various doctors. They're supposed to be overhauling the computers so that they'll know if anyone is abusing prescription drugs. But I know they went doctor shopping.

Mr. John Bryden: I have another question. This isn't just a problem with prescription drugs, it's a problem with non-prescription drugs as well?

Ms. Lorraine Stonechild: Yes, it is.

Mr. John Bryden: You alluded to that. Again, not just within your immediate family experience, are there problems occurring in the urban setting with people getting a lot of access to non-prescription drugs like codeine? There are many other things I can think of as well. Is that occurring also?

Ms. Lorraine Stonechild: Yes, it occurs daily. The only record of anyone who comes to get Tylenol No. 1 is a signed paper. I don't know how often they're able to buy this drug. I know they sign. Codeine is very addictive, and yet it's being sold over the counter, and sometimes it's given by prescription. All you do is go to the pharmacist, sign a paper, and buy it. It's not recorded at all with any of the information on prescription drugs. If you go to a doctor, a prescription is filled, and they tell you Health Canada won't pay for this prescription; you can still get it if you pay for it, and it's not on the record.

The Chair: Thank you, Mr. Bryden.

By the way, I forgot to mention at the beginning that Health Canada's opening statement and the document they tabled with the committee will be lodged with the clerk in both official languages. It is available should anybody want to get a copy of this particular report.

Mr. Mayfield.

Mr. Philip Mayfield (Cariboo—Chilcotin, Canadian Alliance): Thank you, Mr. Chairman.

Ms. Stonechild, you mentioned in your statement that your brother had received, I believe, over 300 prescriptions.

Ms. Lorraine Stonechild: Yes.

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Mr. Philip Mayfield: You've also talked about people getting together and deciding which is the best doctor to go and get them from.

Ms. Lorraine Stonechild: Yes.

Mr. Philip Mayfield: Would that be the way he managed to get hold of that number of prescriptions, then?

Ms. Lorraine Stonechild: I believe so.

Mr. Philip Mayfield: Would there be, in addition to these 300 prescriptions, over-the-counter drugs?

Ms. Lorraine Stonechild: In addition to the 300 drugs, yes.

Mr. Philip Mayfield: We have been—when I say “we”, I'm speaking on behalf of the committee—concerned about these computers and the databases for a long time too.

Mr. Potter, I'm really disappointed with what I heard you say this morning. The reason is that I have seen nothing in what you said about how you and your department have moved on to get hold of the problem. I see a lot of defensiveness about the issue, but I haven't seen the progress the committee has asked you to make. We asked you to submit a report to the committee the last time you were here, I believe it was April 5. Has that report come to the committee clerk yet?

Mr. Ian Potter: No, it hasn't. As I explained, it's in translation at the moment, and it will be available as soon as that's completed.

Mr. Philip Mayfield: Okay.

I'll speak for myself. I'm concerned about this and have been since the Auditor General first indicated that this is a problem that is about a decade old. We've heard the department say the problem was a computer program that had to be completed. Then the computer program didn't work. Now we're involved in privacy issues, and that makes it difficult for the department to deal with this issue. It strikes me that Mrs. Stonechild has offered a solution, asking a patient to agree to have the prescriptions they purchase recorded, which would overcome the privacy problem. It seems there are means of doing this.

What concerns me is that we are here this morning faced with the problem in perhaps its most stark form, the death of people who have been caught up in a system that allows them, for whatever reason, whether it's the lack of responsibility of the pharmacy or the doctor.... I would like to know in specific terms, exactly and in detail, what changes you have administered since the April 5 meeting we had. Could you do that, sir, please?

Mr. Ian Potter: I would like to ask Dr. Cooney to review the steps we have taken since the tragic death of Darcy Ironchild and the steps we are taking right now since the last meeting.

I apologize to the committee if we have given the impression of being defensive. We believe this is a serious issue in Health Canada. We are taking steps within our legislative mandate to remedy the situation. As I outlined, it's more than just Health Canada's ability to solve. We are taking it seriously. I'll ask Dr. Cooney to outline some of the important steps we have taken to deal with that issue.

Dr. Peter Cooney (Acting Director General, Non-Insured Health Benefits, Health Canada): As we mentioned to you in April, we're involved in a number of different areas. The key areas, which I believe will considerably help to address this problem, include the much closer review of the overrides pharmacists do. As your earlier witness mentioned, drugs were being dispensed by using an override system. We are now monitoring those overrides much more closely, in accordance with the recommendation of the Auditor General's department.

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Mr. Philip Mayfield: Regarding the overrides, Dr. Cooney, what happens when you find an override that doesn't make sense to you, that really looks like it should not have taken place?

Dr. Peter Cooney: Then we go back to the pharmacist and question why the override was done. If the pharmacist has a genuine reason, we would pay the claim. If the pharmacist doesn't have a genuine reason, we would not pay the claim. And if that was a continual problem with that particular pharmacist, we would go to the college of pharmacists in that particular province.

So that's one thing we've done.

The second thing we have done—we mentioned this on April 5, and we're continuing to do this—is to place maximum allowable limits on specific drugs and specific items under the program. As the earlier witness mentioned to you, she has a genuine concern with the volume of particular drugs, and she's absolutely correct about that. What we are trying to do, and what we have done in a number of drugs now, is place a maximum above which there will be a cutoff. The intent of this is that it's proactive rather than retroactive. As you know, one of the problems with drug review is that it tends to be retroactive in nature, because you're looking at something that has happened.

Mr. Philip Mayfield: In doing that, have you been able to overcome the privacy considerations we discussed at our last meeting?

Dr. Peter Cooney: Yes, we have. And we have done that by giving the message to the pharmacist that in this specific drug area there's a maximum. This is on a number of items, and we're continuing to expand it.

Mr. Philip Mayfield: Does that mean the patient can then go to another pharmacist and start the procedure over again there?

Dr. Peter Cooney: Well, they can certainly go to another pharmacist, but they would get the same message from that other pharmacist.

Now, one of the problems with this—and Ms. Stonechild referred to this as well—is that if the patient opts to pay for the drug themselves, then the pharmacist would have to determine whether they wanted to dispense it or not. But certainly under the non-insured health benefits program, whatever pharmacist the patient goes to, the same override should appear and the same maximum allowable message should appear, which is not allowable for an override.

The third thing we have done will, I believe, also address one of the key issues Ms. Stonechild mentioned, and that was the problem associated with doctors. We have made the doctor's field mandatory. In the past, as with most third-party plans, a doctor's field didn't have to be entered. If there was no knowledge with the pharmacist of who the doctor was, they could put down what we call a dummy number, in other words 99999, and the claim would go through. We now have placed on the system a system of edits, whereby this can't happen. So the pharmacist now has to identify the doctor as they're putting the prescription into the system, and that in turn alerts the pharmacist if there's a problem. It also alerts the pharmacist if this patient has gone to a number of different doctors and come back to the same pharmacist.

So those would be the three key areas.

The fourth thing we have done is we have an expert committee called the Pharmacology and Therapeutics Committee, which reviews drugs for us regularly. One of the things we have asked them to do—and again, this was one of the items the Auditor General asked us to look into—is to look at potentially misuseable or abuseable drugs. That committee has been doing that for us and has been actually helping us to assess maximum allowable levels on other drugs. So they would, for example, say, delist this drug. It's not a good drug and it's potentially one that could be abused or misused. Or they may say to us, this drug is not a bad drug, but it should be capped at a particular level.

Mr. Philip Mayfield: Mr. Chairman, may I ask one short question to conclude?

Ms. Stonechild, you mentioned that you are involved on the ground in Saskatoon. I'd first of all like to ask you, since April, how many people are you aware of who've died of a drug overdose? I also would like to ask Dr. Cooney, Mr. Potter, or a representative of the department, how many deaths are you aware of since we met in April?

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Ms. Lorraine Stonechild: Just on a social basis, I've talked to around three or four people, and there are one to two persons they know of who have died recently with drug overdoses.

Mr. Philip Mayfield: This is only in Saskatoon?

Ms. Lorraine Stonechild: Yes. Saskatoon and surrounding areas—in Saskatchewan, I guess.

Mr. Philip Mayfield: Mr. Potter, could you answer that question, please?

Mr. Ian Potter: I'm afraid I don't know the numbers.

Mr. Philip Mayfield: Thank you, Mr. Chairman.

The Chair: We may be able to determine that this afternoon when we're videoconferencing with witnesses in Saskatchewan. We may be able to determine that particular answer.

Thank you, Mr. Mayfield.

Mr. Harb.

Mr. Mac Harb: Yes, Mr. Chairman, I have a statement as well as a question.

First, I want to thank our witnesses, in particular Ms. Stonechild. As you have indicated, our deepest condolences go out to her.

It strikes me that there is a series of issues here that affect not only native Canadians but the Canadian population as a whole. In particular, if we were to look at the senior population, where many of them may be taking one, two, three, or four different types of drugs, in some cases, those drugs don't match properly.

The question about the number of natives who have died as a result of overdose could really be asked in terms of the number of seniors who have died as a result of overdose, or the number of people in general who have died as a result of overdose, as well as the different deaths that were caused by people who were taking drugs at a high level, whether prescription or non-prescription.

I can sympathize with Mr. Potter and the problem he has on his hands, which is to balance the whole question of the privacy of the individual versus the protection of the individual, as well as the difficulties we are faced with regarding the issue of jurisdiction, to a large extent.

It strikes me that one of the ways of dealing with this whole problem is if we were somehow to work with the provinces, where, for example, an individual would be designated a doctor, and that would be the doctor that individual would be able to go to, to get prescriptions for drugs, period. If, for whatever reason, he or she were not satisfied with that doctor, then they would have a right to go to another doctor, or maybe a third doctor, within a year. But that's it.

That might respond somehow to the whole issue of dealing with the doctor shopping that takes place, and ultimately this might prove as savings for taxpayers, as well as save lives in the long run.

My question to Mr. Potter is whether or not there are discussions taking place with the provincial health departments in order to devise some sort of system that strikes a balance and at the same time ensures the safety of citizens. I also wonder whether or not—probably the Auditor General could answer this—the Privacy Commissioner is directly or indirectly involved in trying to provide some advice in terms of the best approach to address this issue. I'll stop here.

The Chair: Thank you, Mr. Harb.

Mr. Potter.

Mr. Ian Potter: There are three points, Mr. Harb. You raised the question of whether we are dealing with provinces and other regulatory bodies to see if there are ways in which we could better understand and intervene to deal with this. Yes, we are. This is an area that's regulated by provincial authorities, so it requires us to deal with each of the provinces and the territories, who have the legislative authority to manage and control the behaviour of physicians and pharmacists.

Secondly, you raised the question of whether there is a better way of organizing the system—what we call the primary care system—where people have a designated physician, where there's more oversight of the overall health care and treatment plan of individuals. This is an issue that is under discussion with the federal and provincial governments. It was one of the items that was identified in the accord that first ministers signed in September last year. It's a subject of a federal-provincial discussion as to whether there can be a way to organize what we call primary care so that individuals have a clinic, or a physician, identified with them that would be looking after their overall situation. The individual would be associated with that clinic, and you would avoid the question of doctor shopping.

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Obviously, the physicians' organizations must decide whether they're prepared to support that issue. There are experiments, demonstrations, or pilot programs along those lines going on in the country at the moment. We in Health Canada feel this would add a great deal of benefit to the level and quality of care.

The third question was...?

Mr. Mac Harb: Whether we know the number of people in the general population who have died as a result of this. I know my colleague asked about natives, but I'm interested in statistics on the general population.

Mr. Ian Potter: I'm not aware of that; it's not my area of expertise. I could inquire whether that information is available. I have generally asked for that information, and it appears that this area requires more research. In fact, I will be identifying this area as one that could be pursued by research organizations such as the Canadian Institute for Health Research, to see if there can be some better understanding of the extent of the issue. But at the moment I'm not aware of any numbers.

The Chair: Thank you, Mr. Harb.

Mr. Mac Harb: Mr. Williams and Mr. Campbell were going to answer the question about the Privacy Commissioner.

The Chair: My apologies, Mr. Campbell.

Mr. Ronnie Campbell: Mr. Chairman, we commented in 1993 that there was no legislative basis for the program for non-insured health benefits. We recognize that since then, privacy has become a difficult and changing area.

In our chapter on the year 2000, we recommended to Health Canada that they make sure to have the appropriate tools for dealing with this situation. At that time, the department informed us that they were looking at two options: a legislative base and obtaining consent. They've obviously spent some time on the issue of consent, but that's not necessarily the only option.

The Chair: Did you say, Mr. Potter, that you're contemplating some legislation changes in the province? Did I get that correctly?

Mr. Ian Potter: No, I'm sorry if I gave that impression. What we are proposing is to put in place the steps necessary to get consent, so we can move to that situation rather than trying to deal with it in a legislative manner.

The Chair: So of the options available to you, as Mr. Campbell has pointed out, you've decided to pursue this particular one and leave the rest?

Mr. Ian Potter: The best advice we have at the moment is that we would need consent, even if we had legislation.

I would bring to the attention of the committee members the recent speech given by the Privacy Commissioner to the Canadian Institute for Health Information, in which he underlined the importance of privacy as a fundamental right. Therefore, it's our view that the most practical way of dealing with this situation is to seek consent.

The Chair: You're talking about seeking consent on an individual basis, from each person?

Mr. Ian Potter: Yes.

The Chair: And if they're sick and they don't give it, what are you going to do?

Mr. Ian Potter: I'm optimistic that we will find a way for people to provide us with their consent.

The Chair: But do you have a plan? Somebody goes to a doctor and says, “I'm sick”. The doctor says “Yes, you are, here's a prescription.” But before he can fill that in, he has to give consent. If he doesn't consent, what are you going to do?

Mr. Ian Potter: At the moment, I'm optimistic that we will find—

The Chair: I know you're optimistic, but in that scenario, what would you do?

Mr. Ian Potter: When we reach that scenario, we'll have to develop a proposal that can deal with the situation on its merit.

The Chair: Have you addressed this particular issue yet?

Mr. Ian Potter: We have thought about it, yes. Do we have a policy on it? No.

• 1030

The Chair: Okay.

Mrs. Hinton.

Ms. Betty Hinton (Kamloops, Thompson and Highland Valleys, Canadian Alliance): I think the sensible way is to legislate it. That may be a little too simplistic for some people, but I think when we're talking about this kind of situation, common sense should prevail. The privacy issue should take second place.

One thing I must tell you, Mrs. Stonechild, is that you have my deepest sympathy. I can empathize with the loss of a child—I have had the same pain.

It said 300 prescriptions. Is that in one year?

Ms. Lorraine Stonechild: Yes.

Ms. Betty Hinton: Since there are only 365 days a year, 300 prescriptions is an unbelievable number. But you also mentioned earlier that you knew what was going on and tried to do something about it.

Ms. Lorraine Stonechild: Yes.

Ms. Betty Hinton: Could I please ask who it was you alerted, and how did you do it? By letter?

Ms. Lorraine Stonechild: No. I did it over the telephone. I phoned the doctors. I phoned the physicians and surgeons in Saskatoon, and they told me there was nothing they could do.

I told them about my brother Darcy's drug abuse, about the 300 prescriptions. But they said they didn't get any information from the federal government, Health Canada, the ones that monitor the prescriptions. They didn't get any letters, so they couldn't do anything about that. The letter only came after his death.

It was very frustrating, when I know something could have been done—instead of just talking, talking, and not doing anything. I know something could have been done.

Ms. Betty Hinton: I agree with you. It's been a number of years since I was a pharmacy assistant, but back then controlled substances used to be monitored very, very carefully. I wonder if there have been some changes that I'm not aware of. That's one question I would like to ask Mr. Potter.

The second question is, in your deliberations, have you actually talked to pharmacists and asked for their input on how this might be handled better?

And the third question I want to ask you is whether there's any evidence of prescriptions being sold. Could someone get a prescription and then sell it outside for a profit? Codeine, for example, has always been a very easy-to-sell product. Is there any evidence of that?

Those are my three questions.

Mr. Ian Potter: I'll ask Dr. Cooney to respond.

Dr. Peter Cooney: Your first question was if anything is being done, provincially or in other jurisdictions, regarding specific controlled substances. The answer is yes. This afternoon, hopefully, this committee will get into that area with the folks from Saskatchewan.

A number of provinces have now introduced what they call triplicate prescription plans. When a controlled substance or a narcotic is prescribed by a physician, the prescription has to be issued on in a triplicate form. One copy goes to the pharmacy, one goes to the College of Physicians and Surgeons.... So a system is set up to monitor physicians who may be prescribing more of these drugs. That system is something we might discuss this afternoon.

One of the things we're working on in Saskatchewan is to have this whole process put into an electronic format. At the moment it's a manual system, so it tends to be slow. But this is what the pharmacists wish to do. Of course, this is not a small undertaking, because it involves pharmacy vendors and upgrading the point-of-sale technology component so that the College of Physicians and Surgeons will get the information in real time. The Saskatchewan group will be discussing that with you this afternoon.

The third question was, is there a market for prescriptions? Yes, you're correct, there is, and that's very problematic.

Hopefully, the override we've put in place, and our monitoring the dispensing of the drug, will cut down on that.

• 1035

But I guess the issue comes down to: if somebody wants to purchase something—go to a pharmacy, pay for it himself—then you're coming back to the physician, because our system won't be utilized to track such things. That's where the triplicate prescription component would come in: the information would go back again from the pharmacy to the physician.

So things are looking positive to address issues in those two areas. What was your second question?

Ms. Betty Hinton: I asked if you had spoken to the pharmacists.

Dr. Peter Cooney: Yes, we do. We inform various pharmacies when we get messages. To put this in perspective, the vast majority of pharmacists are very honest and very fair—as are physicians. It's the problematic areas we need to focus on, such as the issue of overrides. If a pharmacist continues to override—that is, gives out the same drug to the same people continually—our system will pick it up, and that's when we go back after the pharmacist.

That was actually one of the recommendations the Auditor General made to us, and one of the areas we have really strengthened over the past six months or so.

Ms. Betty Hinton: In my opinion, there are four responsible parties here—and I think that of the four, pharmacists and doctors are the two with the least responsibility. I think the government should take most of the responsibility, as should the users.

I suppose I resent the fact that it looks as though we're trying to pass responsibility to the people who are actually only doing their job. In fact, the government should be overseeing this. And users need to be made responsible for their actions. We have a really serious situation in this country, and we've got to do something about it. We've got to stop talking about it and actually take some action.

Dr. Peter Cooney: You're absolutely correct, and it's not our intent to shirk any responsibility in this. One issue that's beyond our control, though, is the fact that pharmacists and physicians are licensed under provincial statutes, which govern how they practise. So we need to advise the pharmacists, the physicians, and the colleges of problems. You're absolutely correct, we do need to do that. And we are advising people.

Ms. Betty Hinton: I think this is a perfect example of how the province and the federal government need to work together on many issues in health care, as well as this particular issue.

Dr. Peter Cooney: Hopefully, this afternoon you will see how some of that coordination is working with the folks in Saskatchewan.

Ms. Betty Hinton: Thank you.

The Chair: Thank you very much, Mrs. Hinton.

[Translation]

Mr. Bertrand, please.

Mr. Robert Bertrand (Pontiac—Gatineau—Labelle, Lib.): Thank you very much, Mr. Chairman.

I too would like to thank the witnesses who travelled to be here this morning to talk about a subject I consider very important. I would also like to thank Ms. Stonechild more sincerely. I know it must be very difficult for her to come and testify before us, but I can tell her that her testimony was moving and troubling when she described the circumstances surrounding the death of her brother and her son. I would like to thank her sincerely for being here this morning.

I have two questions, Mr. Chairman, and I assume that both of them are for Mr. Potter.

In your discussions with your department and the other provincial departments, did you consider using a smart card? I know this is being discussed at the moment. I know there is a study on this underway in Quebec at the moment, and I would like to know whether you thought about using a card of this type to monitor doctor's visits and prescriptions.

I will let you answer this question, and then ask my second one.

[English]

Mr. Ian Potter: Yes, we are studying the use of electronic records—or smart cards or record cards—that would allow us to have better information. This is an area where we're looking at two connections. One is a card that would be utilized by both provinces and the federal government. That is under discussion in a federal-provincial context.

• 1040

The other is the interest from Indian Affairs and Northern Development for the creation of a new card, an Indian status card, that right now is just a paper card. This would be replaced with an electronic card that could include a computer chip. It would contain information and could be used in our program.

So we are looking at those two possibilities. It seems that the systems work to develop these things is quite complicated and expensive. So it will take some time to be able to identify what choice we would make.

[Translation]

Mr. Robert Bertrand: I assume that the Information Commissioner is involved in your discussions on developing a card of this type, because as Mr. Campbell was saying so eloquently earlier, this is a very sensitive topic. We must achieve a balance between clients' needs and those of the departments.

[English]

Mr. Ian Potter: Yes, it's a very delicate balance. The interests of privacy of individuals is extremely important. It's important for their health. It's important as a fundamental right. Also, the relationship between the physician and patient is extremely important. I think government has to respect that relationship and respect the authority of physicians to make certain decisions.

We have to work very carefully and delicately when we intervene in the treatment regime of an individual, or we share information about an individual's treatment or condition with others. The fundamental agreement when medicare was first introduced was that physicians would continue to manage the treatment system. It's their decision. It's their professional judgment. And that government would not try to second-guess them.

We get certain information that in situations like this is extremely important and can influence the situation of the patient. I think we have to work carefully with the physicians' organizations and with the provinces to try to find that balance of privacy as well as the balance between our interventions in controlling what we pay for with the decisions of the physician who is providing a treatment regime to the patient.

As Dr. Cooney has said, I know this afternoon you'll be talking with the College of Physicians and Surgeons of Saskatchewan, and I think they will bring these issues before you.

[Translation]

Mr. Robert Bertrand: Something you said in your presentation surprised me a little. On page 9, you say what you are going to do to improve the system. I quote:

Closer monitoring of pharmacists' overriding of beneficiary drug utilization messages at time of submission for payment.

I was not aware that a pharmacist could change what the doctor had prescribed. Is this a fairly common practice?

[English]

Mr. Ian Potter: There's perhaps a misunderstanding. The overrides are a system to identify whether or not there has been a duplicate prescription or whether there are contraindications of the current drug. What we provide is a warning for the pharmacist.

• 1045

As I said, we have to be respectful of the relationship between the physician, the pharmacist, and the patient. We believe it is the professional judgment of those two professions that decide the appropriate treatment regimes for the individual.

We can decide whether we pay or not pay, and we also alert them to what we see may be problems. But we believe it's their professional judgment that has to be respected. We don't want to put ourselves in the position of saying this treatment plan is not good for this patient. So the overrides are warnings of a certain kind, but it doesn't give the pharmacist the ability to change the treatment plan that has been prescribed.

The Chair: Merci beaucoup, Mr. Bertrand.

Mr. Potter, on that question, what kind of override message do you send to the pharmacist if a drug is being prescribed on too frequent a basis? What kind of message does he get on his computer screen?

Mr. Ian Potter: I'll ask Dr. Cooney to reply.

Dr. Peter Cooney: He gets a message, Mr. Chairman, saying there's a problem with a drug that has been requested. In other words, he then has to identify—

The Chair: Is that all it says, a problem with this drug?

Dr. Peter Cooney: It says a frequency problem with the drug. In other words, it alerts the pharmacist. There are different messages depending on what type of area the pharmacist has infringed on. If it's a frequency area—in other words the drug has been dispensed too quickly—he will be advised of that.

The Chair: So if he fills a prescription today, does it say one was issued yesterday too?

Dr. Peter Cooney: It doesn't give the date of the original issuing. It just says this is within a restricted timeframe.

The Chair: So if you get a prescription from the doctor for a two-week supply and you fill the prescription, you now have a two-week supply in your hands. Doesn't the override message say you were given a two-week supply three days ago?

Dr. Peter Cooney: The override message says you were given a supply.... Actually, what the message says—

The Chair: That's what I want to know. What does the message say?

Dr. Peter Cooney: The message gets triggered if the person goes back to the pharmacist within two-thirds of the supply being utilized. In other words, if you were given a prescription for two weeks, you could not refill that prescription for two-thirds of the number of tablets in that.

Now, the pharmacist would then decide. He then knows there is a frequency problem, or the patient may be asking for more drugs than he needs. The pharmacist then needs to ask the patient why he has come back so soon. The patient may provide specific reasons for that.

For example, the patient may be going away and needs.... The patient may have come back after a week to get an extra two-week supply, or the patient may have taken the first drug and not responded properly and is getting a similar drug in the same category prescribed by the physician. At that point, the pharmacist would usually phone the physician and ask whether it is genuine. Did the patient not respond to the first prescription? And the physician would confirm it. So that's why some overrides can be genuine.

The Chair: I'm not suggesting that they're not genuine. What I'm trying to ask is whether the pharmacist is given some real information to make a decision.

Why are we having these overrides? He obviously feels that providing the drug is more important than abiding by the warning. The warning is there because your computer system has identified a problem of, let's say, too frequent a prescription. So we have this dilemma. He has a prescription in his hand and he has a warning. We have the override because he just gives out the prescription. What's wrong with the warning that it isn't giving him sufficient information to say whoops, I shouldn't be filling this?

Dr. Peter Cooney: Well, the warning does give him sufficient information to know he shouldn't be filling it. What he needs to do is determine whether he should override it or not. That becomes the pharmacist's professional decision, and that's tabulated in the Auditor General's report. They will phone the physician in approximately 50% of the cases. They then override the warning with a specific message, so we know, our system knows, why the override took place.

• 1050

The Chair: If the previous prescription of ten days was from a different doctor, would he know the doctor to phone?

Dr. Peter Cooney: He wouldn't know the doctor to phone. He would have the current prescription and would phone the current doctor. He would ask the doctor if there was a reason, because there was a frequency problem. If the second doctor said he didn't know the patient went to a previous doctor, then, hopefully, the pharmacist would not dispense the medication.

The Chair: You don't give the name of the previous doctor. The two professionals, who are capable of understanding the impact of this drug, can't talk to each other because they don't know who they are. Is that right?

Dr. Peter Cooney: We leave it to the pharmacist to decide with the second physician.

The Chair: You told me you don't provide information to the pharmacist on the name of the doctor who gave out the original prescription.

Dr. Peter Cooney: That's correct.

The Chair: How is he going to be able to phone the person, or even advise the current doctor that another doctor, whom he doesn't know, gave out a prescription? They can't talk, can they?

Dr. Peter Cooney: Mr. Chairman, he would tell the second physician there is a second fill on the particular prescription.

The Chair: You're missing my point.

The doctor who has given the second prescription has a professional obligation to treat the patient as necessary. He has, therefore, issued a prescription, not knowing there was one issued ten days before.

You are denying the two doctors the capacity to speak to each other because you will not provide the information.

Dr. Peter Cooney: The pharmacist can speak to the patient and the second prescribing physician. Due to privacy, we can't give the name of the original prescribing physician.

The Chair: I find this quite disappointing. You've known about this problem for years.

Doctors are professionals. If a person goes to Dr. A and Dr. B, he has engaged two professionals to provide for his health. To say privacy prevents the two professionals from talking to each other, to me, is ludicrous.

I can't understand it. Two professionals have signed. They are all competent, qualified doctors. When I go, or anyone else goes, to the hospital, there may be ten doctors who see you. They share the information.

Mr. Ian Potter: Mr. Chairman, our policy is what we believe to be consistent with the Privacy Act. It recognizes that the physicians a patient is seeing is the information of the patient.

Some patients may not want to share the information with their doctor or another doctor. They may have gone to one doctor and want to go to another doctor. They do not want us to share the information.

The Chair: I think it's a fairly naive statement, Mr. Potter, when we have Mrs. Stonechild here because of over-prescriptions for her brother and her son. You take this naive attitude where perhaps they shouldn't be talking to each other. I can't believe it.

Mr. Bryden, do you want to ask some questions?

[Translation]

Mr. Robert Bertrand: Mr. Chairman...

[English]

The Chair: Yes, Mr. Bertrand.

[Translation]

Mr. Robert Bertrand: I would like to ask one last question. I was listening to Mr. Cooney, and from what I understood, the system seems to be working well. My question is this: what happened in the case of Mr. Stonechild? Why did the system not work?

[English]

Dr. Peter Cooney: A very unfortunate series of issues occurred in the case of Mr. Stonechild. First of all, there was a physician who had been prescribing, I believe, fairly liberally. Second, there was a pharmacist who had been overriding the messages and basically was not paying attention to what was on the screen. Then the drugs were being dispensed.

• 1055

We now are in a situation with monitoring of the overrides and internal physician numbers where we can track it and prevent it from happening.

The Chair: You are in possession of a list of all the different doctors a person may use?

Dr. Peter Cooney: We discussed it earlier this morning. We have input physicians' numbers across the country for different physicians. Mr. Chairman, if one physician gets an indication that a patient has gone to another physician, and not divulged the information to the second physician, it should trigger a message in the pharmacist's mind not to dispense the drug. It is the intent.

The Chair: I can't get my mind around this, Dr. Cooney. You are in possession of the information, where maybe four doctors, or two or more doctors, are involved. Yet because of privacy, you feel you can't do anything. They're all professionals. They're all trying to treat the first person's health. We end up, unfortunately, with some very serious consequences.

Mr. Bryden.

Mr. John Bryden: First, I have an observation. It seems to me Health Canada's interpretation of the Privacy Act gives individuals the fundamental right to kill themselves at taxpayer expense. I think it's wrong. I don't entirely blame Health Canada. I think clarification obviously has to come in the privacy legislation.

I'd like to ask two questions. I don't understand why Health Canada doesn't have data on how many people have died as a result of abuse of the non-insured health benefits plan. Remember, it is a fully 100% funded taxpayer plan. People have died.

Why has Health Canada not collected data, not only on the number of people who have died, but also on how many people are affected in urban communities? Why don't you know?

Mr. Ian Potter: As I related the last time I was here, the collection of information on deaths is not something our program does. In order to be able to relate the deaths to our program, it requires the involvement of other organizations.

The question is a legitimate question. Can we find out the information? It's not something that would be automatically produced as part of our administrative program. It would require a special study and particular research. It would require the cooperation of provincial regulatory agencies, provinces, and our program.

Mr. John Bryden: Mr. Potter, who decides to do it? Who decides? If you can't decide yourself, who decides?

I can't understand why it hasn't been done. If it's not your responsibility, then whose responsibility is it? Do we need a Mrs. Stonechild and her tragedy in order to generate this kind of data?

Mr. Ian Potter: As I indicated before, this is under discussion with the provincial registrars of vital statistics, who keep death records and the reasons for death. Although I'm not an expert in this area, my understanding is you would require a fairly specific detailed study of the records and the relationship that caused people to die. This is not something that's fairly easily done.

As I said, it's a legitimate area for study. It's an area of which I have taken note. It is an area we will raise with the research authority as to being an area for priority they may consider as they develop research plans.

Mr. John Bryden: I have a last one.

Mrs. Stonechild, we've heard your testimony. Is there something further you would like to say?

Ms. Lorraine Stonechild: How many more people have to die before all the information is in place? How many more people who are going to die, or have relatives who are dying, am I going to meet on the road?

I get more information out there by walking and talking in the community. In my community, they share information. I don't understand why no one else has the information, especially the ones who are looking after our health benefits, paying for our drugs. It's so confusing. It's so simple, yet it's made so confusing.

• 1100

The Chair: Thank you very much, Mr. Bryden, and thank you again, Mrs. Stonechild.

Mr. Mayfield.

Mr. Philip Mayfield: Thank you, Mr. Chairman.

Mr. Potter, in your opening statement I believe you mentioned that the number of patients who exceed normal doses is very small—was it .05% or 0.5%?

Mr. Ian Potter: It was .05%.

Mr. Philip Mayfield: What would that come out to in real numbers?

Mr. Ian Potter: About 300, Mr. Mayfield.

Mr. Philip Mayfield: About 300, okay. That's a significant number of people.

As we talk about your policy on privacy, as I listen to Mrs. Stonechild, it sounds like a lethal policy. If someone who has been drinking presents himself at a liquor store in Ontario, the sales clerk there is under an obligation not to sell a bottle of wine or whatever it is the person wants. It doesn't have to be very much, they just say no. I presume that if the sale took place and there was a consequence, the guy at the cash register could lose his job.

It's not been unheard of that there are factories people know about where they can go and get prescriptions or buy the drugs they want without too much objection. Is it your experience that this might be taking place? We keep talking about professional expertise and you not wanting to go against that. But how careful are the professionals who are dealing with these people who are dying? Is there due care being taken?

Mr. Ian Potter: I'll ask Dr. Harry Hodes, who is the assistant regional director of community health programs in Alberta, to respond to your question. Dr. Hodes has been deeply involved with this, both as a professional and as a member of Health Canada, and perhaps could give the members some light on the efforts of those professional organizations to deal with the issue.

Dr. Harry Hodes (Assistant Regional Director, Alberta/Northwest Territories, First Nations and Inuit Health Branch, Health Canada): Thank you.

Mr. Chairman, the first thing I must make clear is that I can only speak from my experience in Alberta. I'm not on the national staff of the first nations and Inuit health branch.

I think the question was, how responsible are the professionals for the care of these patients.

Mr. Philip Mayfield: I would be interested more in individual professionals. As Mrs. Stonechild has said, people get together and they know which doctor to go and see, they know which drugstore to go to, to buy the drugs. It would seem that there may be a problem, not with the professions but with a small number of people within those professions. Are you able to identify people like that, who are not careful and cautious?

Dr. Harry Hodes: Yes, you're absolutely right. It is a small number of physicians, and unfortunately, they attract the people who are seeking drugs. They become well known in the drug-seeking community.

Mr. Philip Mayfield: What legislative tools do you have to deal with people like that?

Dr. Harry Hodes: There are no legislative tools, but the College of Physicians and Surgeons of Alberta does have legislative tools and we work closely with them, sharing information on the request of the college.

Mr. Philip Mayfield: Do you have any legislated relationship or control over self-regulating, independent bodies such as the pharmacy associations, the Colleges of Physicians and Surgeons? Do you have a responsibility within those organizations?

Dr. Harry Hodes: Not by way of legislation. They're governed by the provincial acts. But we work with them in a collegial fashion on these issues we're discussing.

Mr. Philip Mayfield: Then I want to ask you, should there be regulation, should there be legislative support for this kind of relationship with the association?

Dr. Harry Hodes: The associations work under provincial legislation, and there is legislation at that level that governs the colleges of pharmacy and physicians.

Mr. Philip Mayfield: Can you cut off a physician or a drugstore that is abusing their position?

Dr. Harry Hodes: We can't, but the colleges can.

Mr. Philip Mayfield: Thank you.

The Chair: Thanks, Mr. Mayfield.

• 1105

As everybody can tell, the bells are ringing. We've got time for four minutes from Mr. Finlay, and then we will suspend the sitting to go and vote.

Mr. John Finlay (Oxford, Lib.): Mr. Chairman, I just had one point to make.

I apologize that I wasn't here earlier, so I really don't want to appear to understand exactly everything that is going on, but I do feel that there have been some strange things said about privacy, doctors, and so on. I happen to have a doctor at home in Woodstock, and I have a doctor here too. They don't communicate, and I'd just as soon they didn't communicate. If I go to another doctor, it's because I'm not quite sure that I'm prepared to accept holus-bolus the opinion of the first doctor. I would certainly take it amiss if the second doctor said, oh, well, I'll just call the first one up and see what he's doing. It's like getting a lawyer. I'm not going to use the same lawyer as Philip when we're going to exchange property; I'm going to get another lawyer.

I think we're making something where there isn't anything and where we've got other things to protect. I feel for Ms. Stonechild. I too lost a child, in a bus accident. With the laws today, he wouldn't be dead, but the laws then weren't the same. We learn as we go and we change them. We don't let kids get off the bus and go around the back any more; they get off and go out the front—at least we do in Ontario, that's mandated. Tragedy we cannot avoid sometimes. It may be luck, intention—who knows? We're not going to cure everything, and we're certainly not going to open up privacy provisions to allow us to say to someone, you mustn't do this, if it's within their purview. That's one of our problems with the Indian Act. It pretends to know what's best for everybody. Well, it doesn't. But we can't then go way over the other side and say, well, somebody died, we've got to tell them how many pills to take. I think we've got to keep a little perspective on what we're trying to do in the long term.

Thank you, Mr. Chairman.

The Chair: Thank you, Mr. Finlay.

I think at this point I will suspend the meeting. We are about 20 minutes short of our normal time, so we will reconvene after the vote, continue for 20 minutes, and then adjourn the meeting.

So the meeting is suspended.

• 1107

• 1144

The Chair: Good morning again, ladies and gentlemen. We will resume our meeting and continue for about 20 minutes, because we were about 20 minutes short when we had to interrupt the meeting for the vote.

• 1145

We apologize to the witnesses, but unfortunately it is a fact of life around Parliament Hill that when the bells ring, the votes are cast, and we have to go to make sure we win or lose the vote, whichever side it is.

Mr. Bryden, you want to ask a question.

Mr. John Bryden: There are just two points I'd like to make, if I may, Mr. Chairman.

First of all, following up on Mr. Finlay's remarks, the privacy issue isn't a question of exchanging the advice of doctors. The privacy issue is whether or not the ability of persons to get multiple prescriptions from various doctors should be protected by the Privacy Act. That's the issue before us.

I want to make another point, too. We've done a little bit of homework here, with respect to whether data has been collected on the number of people affected by the abuse of the non-prescription health program. I wonder if I could ask Mr. Potter to table for the committee, some time in the very near future, the correspondence Health Canada has had with the various registrars of vital statistics, so the committee can better appreciate how active Health Canada has been in pursuing this matter.

The Chair: Is that possible, Mr. Potter?

Mr. Ian Potter: Yes, it is, Mr. Chairman.

The Chair: Okay. What kind of timeframe do you think you could do it in?

Mr. Ian Potter: I could do it within a couple of days. I will ascertain the amount of time needed to translate all the documents.

The Chair: Yes, okay.

We may have to have some translation there, Mr. Bryden.

Mr. John Bryden: I just want to observe, for the record, that one way we can get hold of the cures for this program is if we can understand where the deaths have been and monitor that data, we'll be able to see how effective the solutions we're talking about are going to be in the future.

Finally, I have one specific question to Mrs. Stonechild. There seems to be an issue between overdosing on prescription drugs that have been prescribed and a problem pertaining to non-prescription drugs that have also been prescribed, or at the least obtained, through the non-insured health benefits plan. In her experience with her family, was there an involvement in non-prescription drugs that may have affected the tragedies her brother and son experienced?

Ms. Lorraine Stonechild: With my brother, with the inquest on all the drugs that were in his system...there were non-prescribed drugs in his system.

Mr. John Bryden: Let me ask just one more brief question of Mr. Potter, if I may, Mr. Chairman.

You gave us a chart on page 6 of your presentation that is supposed to disclose the amount of utilization of codeine in benzo-type drugs. Is that data based only on prescribed use of that drug? Does it include non-prescription use of those two drugs, codeine and benzo...?

Mr. Ian Potter: This is from our records of prescriptions. If there was no prescription written, we have no record of that transaction at all. If they didn't pay for it and there was no prescription, it doesn't register with our system.

Mr. John Bryden: But does it register where people acquire codeine that is non-prescription but is paid for under the plan?

Mr. Ian Potter: If our plan pays for it, even if it's an over-the-counter drug, there is a prescription for it. We require prescriptions for over-the-counter drugs, as well as drugs that require prescriptions. If a person pays for over-the-counter drugs out of their own pocket, we have no record of that.

Mr. John Bryden: I have just one final point. I'm just trying to get an idea of this.

If it's something like codeine, which can be prescribed or sold over the counter, the place to catch this abuse is not at the physician level. The physician may not be keeping a record of the actual over-the-counter prescriptions—or maybe he is, I don't know. But is the place to catch it really at the pharmacy's database?

• 1150

Mr. Ian Potter: Yes, I think that's the only place you would have the information on the volume and number of sales of over-the-counter drugs that contain codeine.

The Chair: I have a serious problem. I can understand a privacy situation if somebody walks in and buys an over-the-counter drug that anybody can buy. You can't stop people from first nations and say, “Excuse me, but you have to register as having purchased this”, when other people could buy it and just pay the cash and walk out the door.

Mr. John Bryden: But the point I'm driving at is I think we appreciate that we have no way of controlling the freedom of purchase of an individual, whether it's first nations or otherwise. We can only focus on what's happening within the parameters of the non-insured health benefits plan. That's where the privacy issue comes to bear, because this is a government plan and it would be covered by the Privacy Act. Individual sales would not be.

I'll leave it. I'll pass it back to you, Mr. Chairman.

The Chair: Okay. Thank you, Mr. Bryden.

Mr. Mayfield.

Mr. Philip Mayfield: Thank you very much.

Just to follow up on that point, before I begin what I had in mind, it occurs to me, Mrs. Stonechild, that in your testimony you said that for non-prescription drugs, all that was required of a native Indian person was to go to a pharmacy and sign a sheet of paper. Is that to pass the charges on to...?

Ms. Lorraine Stonechild: No. If they're paying for it themselves, they sign and the pharmacist records what they have and the quantity of it. If someone is going to buy Tylenol with codeine, 100s or 50s, the pharmacist records it. There's no information passed on. Your treaty number doesn't have any effect, but you have to produce ID when you buy Tylenol with codeine over the counter.

Mr. Philip Mayfield: Tylenol 3, is that right?

Ms. Lorraine Stonechild: No, Tylenol 3 is the triplicate.

Mr. Philip Mayfield: I didn't realize I had to produce ID to buy Tylenol.

Ms. Lorraine Stonechild: That's what they do in Saskatoon. When you purchase Tylenol—acetaminophen with codeine—they ask for your ID and record it, just in case you've been there....

Mr. Philip Mayfield: I see. Does everybody have to do that, or just native Indian people who look like they may be using drugs?

Ms. Lorraine Stonechild: I think everyone has to.

Mr. Philip Mayfield: Okay.

I want to ask health department officials something. It seems to me that when there is a problem, despite the privacy considerations, you're still able to go to the College of Physicians and Surgeons or the pharmacy association, and have an entree there and meaningful conversations that people pay attention to.

Why is the privacy there not in effect, the same way it is when you talk to individual doctors or pharmacists?

Dr. Peter Cooney: When you speak on an individual basis with the registrar, the college of physicians, or the college of pharmacists, you speak in relation to the practice of a particular pharmacist. They usually ask you to share information with them on this pharmacist's dispensing practices, or this physician's dispensing practices. You give them what tends to be nominal data.

In other words, it's not patient-linked. It's a specific problem they have that they want to address, or a specific problem you have that you want to address, in relation to the dispensing practices of this pharmacist or the prescribing practices of the physician. So it tends to be nominal data because they're profiling the provider.

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The Chair: Excuse me, if I may ask a question following up on that, I was quite interested in the three-part prescription for controlled drugs that applies to everybody. You're hitting on this point. Why isn't there a problem with privacy for that, but there seems to be privacy for administration of this program?

Dr. Cooney, are you telling me that when the third part of the prescription is turned in to the College of Physicians and Surgeons, or wherever it actually goes—I think that's where it does go—they only collate the information to the doctors who are writing the prescriptions, and they don't check to see that one person might be going to ten different doctors and getting the same prescription?

Dr. Peter Cooney: You will need to ask the physicians this afternoon. My belief is that they probably do. My belief is that this is one of the avenues we are looking at with provincial associations that may answer the problem for you.

The Chair: As far as I'm aware, they do, because I seem to recall situations in the paper where that was the reason for having triplicate prescriptions. It's more to identify the problem users rather than the problem prescribers.

Obviously the Privacy Act doesn't seem to cause a problem there, so I don't know why you're tripping all over this red tape with privacy that prevents you from saving lives as far as the first nations program is concerned. I just can't understand the difference.

Dr. Peter Cooney: The sharing of information occurs under the provincial statutes between the pharmacist and the College of Physicians and Surgeons.

The Chair: So does the provincial legislation provide more latitude than the federal stuff?

Dr. Peter Cooney: The provincial legislation mandates the pharmacist to provide that information to the college, and that's how that can be done. I hope that will be discussed this afternoon.

The Chair: But the federal government doesn't see a need to bring their legislation in line so they could share this information that saves lives?

Dr. Peter Cooney: Well, what we're trying to do, for example, in Saskatchewan is link with the pharmacist such that our information is included.

The Chair: I know what you're trying to do, but you're trying to say you have a problem with privacy.

I do apologize for interrupting here, Mr. Mayfield. I hope you'll allow me to follow this line.

Mr. Philip Mayfield: As long as you give me my time back....

The Chair: I certainly will.

Try to understand your intransigence in dealing with an issue that seems to prevent you from saving the lives of people such as Mr. Ironchild, Mrs. Stonechild's brother, because you get tripped up in, well, we can't do this and we can't do that because it's privacy, and your hands are tied, yet provincially you seem to be quite able to do it. I don't understand why your hands are tied and you keep them tied when you have the capacity to untie them any time you so desire.

Mr. Ian Potter: Mr. Chairman, I do not think we have that ability to change things.

The Chair: The provinces have it. Why do the provinces have the ability?

Mr. Ian Potter: The provinces have their own regulatory and legislative framework in which they operate. We have our own legislative and regulatory framework. Our responsibility is to respect the laws of Parliament as they're set down and as we understand them.

That prescribes certain limits on our behaviour. As I've tried to explain to the committee, within the provisions of the laws of Parliament we are trying to develop methods whereby we can deal with certain circumstances where people may be potentially abusing prescription drugs.

The Chair: I'm sorry, Mr. Potter, I'm just not buying your argument. You told us earlier that you would much rather go the consent route than the legislative route. The provinces obviously have resolved the dilemma. I can't understand why you can't see the need when we have people such as Darcy Ironchild dying of drug overdoses. The provinces can pass legislation where doctors and pharmacists can share information about multiple prescriptions, yet you seem to be totally hog-tied and you can't do a thing.

Mr. Mayfield, I'll turn it back to you.

Mr. Philip Mayfield: Thank you very much, Mr. Chairman.

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It seems to me, if you are relating to the College of Physicians and Surgeons, and pharmacists, about individuals you are concerned about, particular individuals you have noticed and perhaps marked down, who in your opinion have abused the system for whatever reason, do you not have the authority to say to a pharmacy that you will no longer pay the bills totalled up for clients, that they will have to go somewhere else rather than that store, or you will no longer pay for prescriptions that a particular physician writes? Do you do that, or do you just continue to take the professional advice?

Mr. Ian Potter: We follow certain guidelines and procedures with respect to pharmacies. If we believe the practice in a particular pharmacy is inconsistent with general standards, then we have the opportunity or the possibility of delisting that pharmacy—that is, we will not pay the bills that come from that pharmacy. That does happen.

We are not able, nor are we empowered, to regulate physicians. We do not pay for physicians; the provinces pay for physician services. The physicians are governed by their own regulatory organization. It is that organization that can suspend or discipline a physician where they believe a practice is inconsistent with standards.

So with respect to pharmacists, we monitor, and where we believe the practice is inconsistent, we can suspend for a period of time or forever.

Mr. Philip Mayfield: Would there be an instance where it would be noted on the pharmacy computer screen that such-and-such a physician's prescriptions will not be honoured?

Mr. Ian Potter: No.

The Chair: Thank you, Mr. Mayfield. Do you have any more questions?

Mr. Philip Mayfield: Yes, I have a couple more.

The Chair: Okay, and then Mr. Bryden has one, and I have a couple myself, and then we'll wrap up.

Mr. Philip Mayfield: With regard to the issue of privacy, I had in mind asking you how the negotiations are going with the Assembly of First Nations and others that you may be negotiating with. But I'm inclined at this point to try to express my concern about your overzealous caution, if I may put it that way.

It seems to me you've demonstrated a need to be very cautious, to stick exactly within the legislative boundaries. I'm certainly not suggesting that you should gleefully jump over these boundaries, because we do have order and we have it for a reason, but it seems to me that the department is so cautious, so conservative, that in fact you're prepared to worship the conservatism that you have rather than show a first concern for those who are suffering from, in my mind, a lack of action that needs to be taken by your department.

Having said that, I want to turn to the Auditor General's people, to Mr. Campbell, or whoever you would like. I'd like to refer to your statement where you note:

...we are concerned that the department has not made sufficient progress to fix many of the problems identified. We remain deeply concerned that the program allows individuals to access excessively high levels of prescription drugs.

So I want to ask you very specifically, if you will, please, to lay out your concerns for the committee and for all who are here to listen to you. Would you do that, please, Mr. Campbell?

Mr. Ronnie Campbell: Yes, indeed. Thank you.

We had raised several concerns in 1997 concerning the point of service system that was about to be put in place. At that point, the department was piloting the system, and it certainly had a great deal of potential. We were concerned that with the information that was being provided at that time, the plan was to provide the pharmacist with the dates of the last three prescriptions. In addition to that, the department had informed us at the time that it intended to strengthen those warnings it had planned for the system. We had said that since the pharmacists could override those warnings in that case, it was important that the department closely monitor those overrides by pharmacists.

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The system that was finally implemented was one that plugged in a little less information than had initially had been planned, and the warnings had not been strengthened, as the department had indicated they would. But probably more importantly than those, the action the department said they would undertake in terms of monitoring those overrides had not adequately been done at the time of our audit.

I know the department has made commitments to us in response to the chapter, and certainly Mr. Cooney said this morning that several of those actions have been undertaken since the time of our audit. However, the information we have is the information we had at the time of the audit. We will certainly be following up on all of the responses in the chapter and the commitments made.

The Chair: Thank you, Mr. Campbell.

Mr. Bryden, one last question.

Mr. John Bryden: Mr. Potter, how much is the non-insured health benefits program worth? How much does it cost the taxpayer?

Mr. Ian Potter: It's approximately $578 million.

Mr. John Bryden: Half a billion dollars.

I'd like to address one remark to Mrs. Stonechild. Mrs. Stonechild, you've heard Mr. Potter and others being put really on the spot here with respect to this program and the fact that people have continued to die, even though there have been complaints over the years. I'd like to make an observation on behalf of Mr. Potter and the people in his department. In my mind, it is not their fault, it's Parliament's fault. This is a huge expensive program to be run without legislative authority. To call upon the Health Canada people, like Mr. Potter—I'm sure he would always act in the best interests of his portfolio—to interpret the Privacy Act is unfair, in my view. What I've heard today here is that it's not Health Canada that's failed you; it's Parliament that's failed you because we have allowed a program like this to go on for so long without defining it in legislation.

I hope, Mr. Chairman, that's one thing we'll try to correct.

The Chair: Thank you, Mr. Bryden. And I'm sure that our report will reflect your comments, no question about it.

Mrs. Stonechild, I know this is difficult, but can I ask you, how was Darcy's health in the last year, when he had those 307 prescriptions? Was he—can I use the term—a normal person?

Ms. Lorraine Stonechild: I communicated with Darcy mostly over the phone and when I saw him on a bus. I didn't visit him regularly because I knew there was prescription drug abuse going on. There were times when I felt he was normal, and other times I felt he wasn't. Sometimes I didn't know who I was talking to, because it was up and down, up and down, and his life was up and down.

The Chair: Yes. And the reason I asked that is that when he would go to the doctor to get another prescription, I'm sure at times he would have looked a bit abnormal, under the influence of drugs, and yet he got another prescription. That bothers me, that these things would be prescribed under these conditions.

I'm looking at the Saskatoon StarPhoenix of April 21, 2001. I think I'm quoting when they're saying that:

...Darcy...was able to collect a stash of more than 160 mind-altering drugs, including Valium, Demerol and chloral hydrate, a sleeping medication.... He also got scores of antidepressants, anti-anxiety drugs, antibiotics, anti-inflammatory medications and over-the-counter drugs such as Gravol, Maalox, Tylenol and ibuprofen.

Dr. Cooney, you were saying that in your messaging systems to pharmacists you have limits on drugs. But I got the impression that these limits were on a particular drug: if one particular drug was being overused, a message would come up. But if somebody was using Gravol, Maalox, Tylenol, ibuprofen, Valium, Demerol, and chloral hydrate, all within your limits as for individual drugs, but collectively they're extremely damaging, I get the impression your messaging system wouldn't pick that up.

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Dr. Peter Cooney: Mr. Chairman, the messaging system picks up in two ways. One is exactly what you're saying: if it's a specific drug. The other one is if it's in a specific drug category. The messaging system should pick up the specific drug category and give a warning to the pharmacist. So you're correct: in the first part the messaging wouldn't pick it up, but the second part would—i.e., the drug category.

The Chair: If someone is getting a wide range of drugs, is he being protected by this warning system you have devised?

Dr. Peter Cooney: Yes, he is, because that wide range of drugs is within a specific category or categories.

The Chair: Yes. Well, I take Mr. Bryden's comments to heart that perhaps we have failed, Parliament has failed, without giving the direction and the authority to Health Canada to provide a program for our first nations that provides what they need yet at the same time ensures protection.

When people get addicted, the capacity to restrain themselves, as we all know, is severely reduced. Therefore, they will go to great lengths to obtain these drugs, and we need these safeguards in place.

One very quick question, Mr. Mayfield.

Mr. Philip Mayfield: On that particular point, we've talked about legislation, and I think it was in my conversation with Mr. Potter earlier about the need for legislation. You can clarify for me if you will, please, sir.... I didn't get the impression that you were asking for legislation or feeling a need for legislation to support what you were doing.

My colleagues are suggesting that we need to have legislation, and I'm not about to disagree with them, if that would support you in what needs to be done, because I'm pushing you as hard as I can to do what's necessary for your department to intervene and to be a benefit to the people who look to government service.

What is your impression about the comments of Mr. Bryden and Mr. Williams? Do you think that legislation would better support you in the job you have to do?

Mr. Ian Potter: The decision of whether there should be legislation or not is probably beyond my—

Mr. Philip Mayfield: Sir, please don't be cautious. Help us out.

Mr. Ian Potter: As any public service would say, legislation is a better guide than policy.

The Chair: On that note, Mr. Mayfield, I would like to thank Mrs. Stonechild for coming here this morning.

We know it has been a difficult and trying time for you, and to come forward and discuss it in public is even more heart-wrenching. But we are glad you have shared your story with us, and we hope that by coming forward today you have made a contribution to improving the program so that you will be able to see your children and your grandchildren grow up healthy and strong.

I also thank the other witnesses for coming along this morning.

There will be another meeting at 3:30 this afternoon in Room 701, La Promenade Building, and that's at 151 Sparks Street.

The meeting is adjourned.