SNUD Committee Meeting

37th PARLIAMENT, 1st SESSION

Special Committee on Non-Medical Use of Drugs

EVIDENCE

CONTENTS

Wednesday, August 28, 2002

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The Chair (Ms. Paddy Torsney (Burlington, Lib.))

Dr. Brian Taylor (Deputy Registrar, College of Physicians and Surgeons of B.C.)

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The Chair

Mr. Peter Hickey (Pharmacist, College of Physicians and Surgeons of British Columbia)

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The Chair

Dr. Brian Taylor

The Chair

Dr. Brian Taylor

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The Chair

Ms. Coleen Conway (Manager, Prescription Monitoring Program of Nova Scotia)

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The Chair

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Dr. Dennis Kendel (Registrar, College of Physicians and Surgeons of Saskatchewan)

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The Chair

Mr. White (Langley—Abbotsford)

Dr. Brian Taylor

Mr. Randy White

Dr. Brian Taylor

Dr. Dennis Kendel

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Mr. Randy White

Mr. Peter Hickey

Mr. Randy White

Mr. Peter Hickey

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Dr. Brian Taylor

Dr. Dennis Kendel

Mr. Randy White

Dr. Dennis Kendel

Mr. Randy White

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Dr. Dennis Kendel

Mr. Randy White

Mr. Peter Hickey

Mr. Randy White

Dr. Brian Taylor

Mr. Randy White

The Chair

Ms. Hedy Fry (Vancouver Centre, Lib.)

Mr. Peter Hickey

Ms. Hedy Fry

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Dr. Dennis Kendel

Ms. Coleen Conway

The Chair

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

Mr. Peter Hickey

Mr. Derek Lee

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Dr. Brian Taylor

Mr. Derek Lee

Dr. Dennis Kendel

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Mr. Derek Lee

La présidente

Dr. Brian Taylor

The Chair

Dr. Brian Taylor

The Chair

Dr. Brian Taylor

The Chair

Dr. Brian Taylor

The Chair

Dr. Dennis Kendel

The Chair

Dr. Dennis Kendel

The Chair

Dr. Dennis Kendel

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The Chair

Dr. Dennis Kendel

The Chair

Mr. Peter Hickey

The Chair

Dr. Brian Taylor

The Chair

Ms. Coleen Conway

The Chair

Dr. Brian Taylor

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1600

The Chair

Dr. Brian Taylor

The Chair

Dr. Dennis Kendel

The Chair

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1605

Ms. Coleen Conway

The Chair

Mr. Peter Hickey

The Chair

Mr. Peter Hickey

Dr. Dennis Kendel

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The Chair

Mr. Peter Hickey

Dr. Brian Taylor

The Chair

Dr. Dennis Kendel

The Chair

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Dr. Dennis Kendel

The Chair

Ms. Coleen Conway

The Chair

Mr. Derek Lee

Ms. Coleen Conway

Mr. Derek Lee

Ms. Coleen Conway

Mr. Derek Lee

Ms. Coleen Conway

Mr. Derek Lee

The Chair

Ms. Coleen Conway

The Chair

Ms. Coleen Conway

The Chair

Ms. Coleen Conway

Dr. Dennis Kendel

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Mr. Derek Lee

Dr. Brian Taylor

Mr. Derek Lee

The Chair

Dr. Brian Taylor

The Chair

Dr. Dennis Kendel

The Chair

Mr. Kevin Sorenson (Crowfoot, Canadian Alliance)

Dr. Dennis Kendel

Mr. Kevin Sorenson

Dr. Dennis Kendel

Mr. Kevin Sorenson

Ms. Coleen Conway

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1625

The Chair

Mr. Peter Hickey

The Chair

Mr. Peter Hickey

Dr. Dennis Kendel

The Chair

Dr. Brian Taylor

The Chair

Ms. Carole-Marie Allard (Laval East, Lib.)

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Dr. Dennis Kendel

Ms. Carole-Marie Allard

Dr. Dennis Kendel

The Chair

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CANADA

Special Committee on Non-Medical Use of Drugs

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NUMBER 055

l

1st SESSION

l

37th PARLIAMENT

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EVIDENCE

Wednesday, August 28, 2002

[Recorded by Electronic Apparatus]

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[English]

    The Chair (Ms. Paddy Torsney (Burlington, Lib.)): I'll call this meeting to order. As everyone here knows, we are the Special Committee on Non-Medical Use of Drugs, struck pursuant to an order of reference from the House of Commons in May of 2001 to consider the factors underlying or relating to the non-medical use of drugs. In April of this year we were also given the subject matter of a private member's bill, an act to amend the Contraventions Act and the Controlled Drugs and Substances Act relating to marijuana.

    We are pleased to have with us this afternoon, from the College of Physicians and Surgeons of British Columbia, Dr. Brian Taylor and Peter Hickey, who's a pharmacist, and from the Nova Scotia prescription monitoring program, Ms. Coleen Conway, the manager of that program. Also, colleagues, when his plane arrives, we will have with us Dr. Dennis Kendel, registrar for the College of Physicians and Surgeons of Saskatchewan.

    Over to you, Dr. Taylor.

    Dr. Brian Taylor (Deputy Registrar, College of Physicians and Surgeons of B.C.): Thank you very much for your interest in the work of the College of Physicians and Surgeons of British Columbia and for inviting us to be with you this afternoon. I'm a physician. I'm accompanied by Mr. Peter Hickey, who is a pharmacist and has a much more impressive provenance than mine, in that he is originally from Ottawa. He was with the Bureau of Dangerous Drugs here and plays a very important role in our drug programs in British Columbia.

    Our first slide is a picture of the college in B.C. I'd like you to note the blue sky and the green leaves. That's in February, of course.

    We have three drug programs, mainly. Our programs can be split into three. The triplicate prescription program was introduced in 1990. Essentially, it is a program that covers the main narcotics, with a few drugs like Ritalin added. It requires a special prescription pad, which is difficult to forge. It, in itself, has been a very important adjunct to care in B.C., in that forged prescriptions in our province are uncommon. It's not impossible to forge them, but it is uncommon.

    In 1995 there was an assumption of the methadone program for the province by our college. We administer it. Mr. Hickey is totally responsible for that, and he's going to present to you very shortly and describe the program in detail.

    We also have a prescription review program, which is a program that reviews the use of benzodiazepines and non-triplicate narcotics like Tylenol 3. Tylenol 3 is a drug of particular barter value on the street, so it is perhaps of interest to you.

    Our programs have been mightily enhanced by the B.C. PharmaNet program introduced by the provincial government in 1995. In brief, every prescription that is dispensed in the province of British Columbia is captured into a database. The College of Physicians and Surgeons has its own stand-alone database. The drugs we review are downloaded automatically each day. I'll give you a little more on PharmaNet in a moment, if I may.

    I think it's very important to understand what the College of Physicians and Surgeons attempted to do with the drug programs. We're not the watchdog of B.C., and I would really like to emphasize that to you. The College of Physicians and Surgeons expects that patients with acute or chronic pain should receive appropriate clinical assessment and pain relief, that is, the college is not opiophobic. We recognize the appropriate clinical use of these important drugs. The responsibility for all prescriptions, including the choice of drug, the dose, and the frequency of dosing, lies with the prescribing physician. The physicians retain responsibility and the ability to choose drugs for the treatment of their patients, and they maintain total control of patient care and their own narcotic prescribing.

    I apologize if you are already aware of these two definitions, but they're quite important definitions from Russel Portnoy, who is a real expert in the issues of pain and addiction: “Physical dependence is a physiological phenomenon defined solely by the development of an absence syndrome following abrupt discontinuation of therapy”, whereas addiction is a “psychological and behavioural syndrome characterized by loss of control over drug use, compulsive drug use, and continued use despite harm.” I would emphasize that the college of British Columbia understands the difference between drug seeking and seeking relief of pain. That's an important thing to understand with our monitoring programs.

    What do we review? When we're looking at our database, we look for high use profiles, both of prescribing and of patient use. We look for patients that are multi-doctoring. We have an automated program that identifies patients who are seeing more than five physicians a month. That may seem a high number to you, but it reflects the reality of walk-in clinics and, of course, specialty care.

    We monitor the use of office use medications, self-prescribing, or physicians who are self-prescribing, and the methadone patients. Our database is terribly important to the work of the methadone program. We also review the profiles of physicians who have undergone treatment for their own substance use disorder. Also, we have new software that allows us to monitor the use of drugs of possible concern. If there seems to be a narcotic that is being heavily used in the province, we can look at that individually, as either a group or an individual drug.

    The PharmaNet program, as you may well know already, is a joint venture of the Ministry of Health's pharmacare, the College of Physicians and Surgeons, and the College of Pharmacists of our province. All prescriptions are electronically captured at the time they are dispensed so the data are very current: we can see what the patient received earlier today.

    The college introduced two pilot projects. We now have the PharmaNet database in all emergency departments in British Columbia, so the emergency room physicians can provide immediate care using the PharmaNet database and the current patient's drug profile. We also have a successful pilot and are hoping to fan out the PharmaNet database into physicians' offices, which I think will make physicians very aware of the patient's drug profile and perhaps give pause at the time of prescribing.

    The whole of the PharmaNet program has been reviewed by the Privacy Commissioner and has been approved. I think the PharmaNet program might be something to be considered across Canada as a means of addressing some of the problems with diversion of prescribed drugs.

    Very quickly, I would advise you that our program is proactive. The physicians of the province support the various drug programs the college has in place, and their success is a reflection of that. We are not a watchdog. We try not to interfere with good care. We try to provide resources for the physicians of the province. We have constant communication with the members of the profession with regard to multi-doctoring patients. We have an advisory committee of clinical pharmacologists and folk of that ilk, which serves as a resource for the profession. If physicians have problem patients, we can give them advice. We use the database for the disciplinary work of the college as well, of course.

    We have workshops on chronic pain management, so we run some educational initiatives that the physicians attend voluntarily, but if a physician appears to be having difficulties with prescribing, he or she is invited by the college to come and attend our workshops. Similarly, we have workshops for methadone prescribing, which Mr. Hickey will refer to.

    As an example of the sort of work we can do with our database, which is so complete, it was inferred that the drug Ritalin was being inappropriately used in our province. As I am sure you are aware, Ritalin, when combined with Talwin, was a drug of diversion some years ago. It's less so now. As a result, we looked at a six-month study window. At that time 6,769 children in our province were receiving the drug. It was prescribed by 2,092 physicians. We wrote to them all with a questionnaire and had a response rate of 92%, which is unique, I think, in any study on Ritalin and is a reflection of the cooperation the profession shows with the work of the college. The result was that in B.C. 0.8% of children in the 0 to 15 age group were receiving Ritalin in the study period, which is well within the norm.

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    On benzodiazepines, I have given you a coloured graph that I would like to refer to. We reviewed the use of benzodiazepines in our province because, again, it was a drug of diversion, or allegedly a drug that is diverted to street use and allegedly overprescribed and a source of concern. If you will be kind enough to refer to the coloured graph you have in front of you, I would like to point out a few things that might be of interest to your committee.

    If you look at the red line with the squares on it, that represents the benzodiazepine tablets dispensed per capita across Canada. We're looking at the years 1997 to 2001. It's a straight line: there is no increase in use across Canada. There is a variation between provinces, though. If you look at the little box on the right, it gives you an indication of which province we are referring to. British Columbia is on the left, and as you can see, benzodiazepine use in British Columbia is actually among the lowest in the whole of Canada. If you look again, it reflects the Canadian-wide experience. It's a straight line and it goes the same for every province. There has been really very little change in benzodiazepine use across the country. I cannot explain to you why the use in New Brunswick, Quebec, and Nova Scotia is so high--you recognize that this is per capita of population--but again, even in the high use provinces the graph would appear to be a straight line.

    We also in our province--and please indicate to me if you feel I'm getting off topic--use our database to conduct a survey on pain control for cancer patients, a very important topic in our province. It was a joint study conducted by the UBC division of palliative pare, the B.C. Cancer Agency, the Department of Family Practice at the Vancouver Hospital, and the college. The college did the spade work, and its purpose was to ensure that all cancer patients in B.C. received effective pain management and that if any barriers existed in patients receiving appropriate care, it would remove them. The reason for this was that it had been inferred that our triplicate programs and drug programs interfered with patients getting adequate narcotics and pain control and that it was possible that the college programs were interfering with appropriate care. That was of great concern to us, of course, and that was the reason for this study. Again, just to emphasize to you, we surveyed almost 7,000 physicians. We had a 42% response rate to the first mailing, a final response rate of 67%. The previous best study in Canada had a 19% response rate. I think the colleges do have a role to play in this sort of work and these sorts of reviews.

    I will move on, because I want to leave some time for Mr. Hickey, who has some very important stuff to tell you about.

    I would, as an example of the work we do, refer to OxyContin. I want to emphasize that this relatively new, long-acting narcotic is not unique. Many of the narcotics marketed in our country are sought after and are diverted. OxyContin is just one that has attracted a lot of attention because it was the focus of a study by the American Society of Addiction Medicine. It is a great drug, it's a good analgesic, it comes in a variety of strengths, so it's nice to tailor the narcotic dosage to the patient. It doesn't contain any aspirin, so these poor sick folk don't bleed from the gut, it doesn't have any acetaminophen, which can damage the liver, and it has been well received by patients and physicians. The one downside to the drug in Canada at the present time is that it's pretty expensive.

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    Unfortunately, it has been well received by addicts as well. The tablets are crushed and snorted or dissolved for IV use. Because both routes give an immediate high, it has been well received. Apparently, the 40 milligram tablets are the most popular. To give you an idea of the social impact this has had in the United States, sixty 40 milligram OxyContin tablets retail for $300 U.S., but the same drugs would attract $2,400 on the street. Typically, addicts use 200 to 300 milligrams daily, I'm informed. Now the diversion of this drug has been recognized by the manufacturer, and it is currently developing a new product that will contain beads of the anti-opiate Naltrexol, which apparently will make the drug less rewarding for the addict.

    OxyContin is not a big problem in our province thus far, although we have identified a few cases where it appears to have been diverted. For example, a 30-year-old man had complex regional pain syndrome, meaning he had pain in the thigh and buttock. He was properly worked up medically and was recognized to have a chronic pain syndrome. He couldn't afford to attend the pain clinic, but he could afford his OxyContin. The following is the dosage he was receiving. In the first eight days of January he received 1,800 tablets. The cost of 2,000 tablets of OxyContin in Canada is approximately $4,400, so this gentlemen was probably profiting from this drug.

    Then we have an example of a very sick patient who clearly needed proper care and proper narcotics, but she was getting excessive quantities of a drug called Dilaudid and a drug called Diazepam. The college intervened in this case, using our programs. She was receiving these doses per month. We intervened, and she is now getting really good care. She has maintenance therapy with Mr. Hickey's program. She's now receiving 60 milligrams of methadone a day, a very cheap drug, far cheaper for the province and far better for the patient.

    That is an example of the sort of work we do. I will not bore you with what I thought was fascinating stuff when I prepared the slides. If you just bear with me, I'll page through these last slides. I do have some handouts. If any of you have any questions on any of this other stuff, I'd be happy to talk with you about it afterwards.

    I would like to make reference to the evidence-based recommendations for the medical management of chronic non-malignant pain that was developed by the Ontario college. We have endorsed that document. We circulated it to our members. It comes as a reference guide for clinicians and it is available on our website. I'd like to acknowledge the obvious concern that exists in Ottawa with regard to the relief of chronic pain, and I note that you've done your bit.

    Thank you.

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    The Chair: Thank you.

    Now over to you, Mr. Hickey.

    Mr. Peter Hickey (Pharmacist, College of Physicians and Surgeons of British Columbia): I'd like to share with you the history of the British Columbia methadone program, which is currently Canada's largest methadone program. In approximately 1995 the College of Physicians and Surgeons realized that British Columbia had the lion's share of heroin and narcotic addicted people in Canada. There were a lot of problems at that time with the methadone program. As you are aware, the program was administered from Ottawa, and the program was less than perfect at that time. There was approximately a six to eight week waiting period for patients to enter the methadone program. At that time the college felt we could perhaps do a better job in administering the methadone program than Ottawa was doing, and so we made application to Ottawa that we assume the administration of the program, although the Minister of Health retained the ultimate responsibility. We became the first and only college of physicians and surgeons in Canada administering its own methadone program, and that is still the case today.

    When we assumed the administration of the program we had a number of objectives in mind, the first one being to increase the number of physicians involved in methadone treatment, thereby increasing the number of patient slots available for patient care, but also to improve the quality of care in the methadone program. In approximately 1996 in British Columbia there were about 110 physicians authorized by Ottawa to prescribe methadone. You will see in the chart that currently we have 570 physicians authorized to prescribe methadone, and that is the largest number in Canada. As you can see in this graph, from 1997 to 2002, we have over 8,000 patients currently receiving methadone maintenance therapy.

    The college maintains two databases. This particular one indicates patients currently in treatment, and the second, which has over 13,000 patients, indicates the number of patients who have entered methadone treatment at any given time. For obvious reasons, sometimes patients enter treatment and then drop out through non-compliance. There is a high death rate in this group of patients as well.

    You will see by this graph from 1991 that we had 195 patients receiving methadone treatment. Since the college took over administration, the number has increased exponentially.

    The college's program is an extremely good one. We have a number of golden rules that physicians must adhere to. We run a good program. As I mentioned, the objective was to increase the quality of care in the program. We have an assessment portion of the program, where patients must find a methadone-trained physician, and acceptance into the methadone program will be contingent upon each patient receiving an addiction medicine assessment. I haven't put the slide in here, but there are a number of criteria a patient must meet.

    Although we want to increase the number of spaces available for patients, we want to ensure that patients who do receive methadone indeed require methadone. For instance, we wouldn't want patients coming into a methadone program who had a dependency on Tylenol 3. We want to ensure that they are heroin dependent patients.

    The dosage of our program, because we do administer our own program, is individualized, which is different from the old federal guidelines, which stated that the maximum daily dosage of methadone was 100 milligrams. We believe that dosage has to be individualized for each patient.

    In our program daily witnessed ingestion of methadone is the norm. Carry privileges are considered when the patient is deemed to be stable, and these carry privileges must be approved by the college. Urine monitoring is done at random and on a supervised witness basis.

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    We expect that periodic reassessment of patients and referrals to other treatment modalities will occur.

    As far as the physician authorization process is concerned, we have a very stringent process, and they must adhere to that if they want to receive an authorization to prescribe methadone. They have to apply, obviously, to the college. It's mandatory that they attend our methadone training workshop 101. That workshop is the only one of its kind in North America, and we currently train physicians from right across Canada and also from the United States. Every physician has to have an interview with myself. In addition, we have a preceptorship program. The physician must go through a college audit of his methadone program within the first year. We also expect that the physician will receive 12 hours of CME training in addiction medicine within the first year.

    I mentioned education and quality of care in this program. We have developed within the program, as I have mentioned, methadone training workshop 101, which deals with counselling techniques, the pharmacology of methadone, and the use of methadone in pregnancy. We use actual methadone patients, and we have physician-patient interviews for half a day, where physicians are required to apply the skills that, hopefully, they have learned in the morning session. In addition to that, we have methadone training workshop 201, which deals with more advanced pharmacology and more advanced techniques in the use of methadone in pregnancy and with anti-retroviral medications for HIV patients.

    The methadone program, as I say, has a monitoring process. At the college we do approximately 100 methadone audits per year. We send two auditors from the college, and they spend approximately half a day with each physician going through their methadone program. A formal report is then submitted to the advisory committee on opiate dependency. If the audit doesn't go well, we may very well call the physician in so that we can review their philosophy of addiction medicine and of methadone treatment specifically.

    We maintain a methadone patient database, and Dr. Taylor referred to that previously. In this database, because of the PharmaNet system and the triplicate program in British Columbia, we are able to assess the medication requirements of all these patients. We regularly look at these patients to ensure that each patient is being treated by only one methadone physician, the patient is getting an appropriate dose, and the patient is getting an appropriate carry and to ensure that patients are getting methadone. They shouldn't be getting other psychoactive medications. However, we do realize that methadone patients have accidents. They do get ill as well. We would contact the physician, for instance, if we noted that a patient was getting 100 milligrams of methadone and a regular supply of Dilaudid. We would want to know why that was. It might be perfectly appropriate, but we would want to know that. We are able to look at all the prescribing of these psychoactive medications. As Dr. Taylor indicated, we do maintain a triplicate database and a PharmaNet database, which allows us to look at that medication.

    In this program we'd also want to know if methadone patients are multi-doctoring and getting other psychoactive medications from other physicians. Benzodiazepines are a major concern in this patient population.

    I mentioned the physician audits. We do approximately 100 per year. Our auditors go out to the methadone facility. They are looking at the methadone clinic and staff. They will go through actual clinical records and the assessment forms for patients. They are looking at actual patient care, urinary drug screens, the average dose, carry privileges, referrals to other treating agencies, and other treatment modalities. We want to see that there is a long-term treatment plan in place to ensure that these patients are getting proper care.

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    Briefly, I will share with you some statistical information on our program. You will notice that this slide shows the relationship of patients receiving methadone as a carry privilege and methadone as a daily witnessed ingestion. The norm in our program is daily witnessed ingestion. You will see that we have over 5,000 patients receiving methadone as a daily witnessed dose. That is a very high proportion.

    This slide is a comparison of patients treated in methadone clinics with those in private practice. What makes our program unique in British Columbia and is of great interest, for instance, to the United States is that we have a very good mix of patients receiving care from a clinic setting and also from a private physician. You will see in this slide that the vast majority of patients receive methadone from a clinic setting, with 2,700 receiving methadone treatment from private physicians.

    In this slide we have a comparison of physicians in clinics versus private practice. The slide sort of reverses itself where you see the number in clinics versus private practice.

    This slide shows the geographical distribution of methadone authorized physicians in British Columbia. One of our objectives when we took over the administration of the program was to make methadone treatment available to all British Columbians throughout the province. We have been very successful in doing that. You can see by this slide that 44% still reside in the lower mainland, but we have a good mix of physicians around the province. There are very few communities right now in British Columbia where a patient wishing to secure methadone treatment can't do so.

    We were also successful several years ago in introducing methadone into the provincial corrections systems, and the federal system as well. This is unique. We do have physicians in the jails and in corrections. We also go into those correctional facilities and do audits, which is a little bit of a twist for us.

    This slide will show you the method of heroin use prior to methadone maintenance treatment. You can see that 62% of the patients were using heroin by IV, 20% by smoking, and 15% intranasally.

    Several years ago one of the main criteria for entering a methadone program was that you had to be an IV heroin user. We have changed the admission criteria recently, because we have a fairly large problem in British Columbia with some of the ethnic populations smoking heroin--chasing the dragon--particularly the younger populations. We changed our admission criteria, although if a patient is admitted with an addiction to smoking heroin, there is a sunset clause. We don't want to see patients on methadone indefinitely. We'll say they can be put on a methadone program, but there has to be a sunset clause. We want to see them coming off in six or eight months or something like that.

    Next is the percentage of other drug use prior to methadone maintenance. Our program allows us to do this. You can see here 79% with opiates, 28% of our patient population with benzodiazepines, 45% with cocaine, and 34% with marijuana, also nicotine smoking and alcohol.

    As you are probably aware, cocaine is a major problem in Vancouver. Methadone is not indicated for treatment of cocaine addiction. However, patients with a cocaine and heroin addiction very often will benefit from a methadone program.

    This is an interesting slide, diagnosis prior to methadone maintenance treatment. Obviously, pregnancy refers only to females--and it is in pink so it doesn't confuse anyone. Some 39% had hepatitis C. One per cent of our patients had a diagnosis of AIDS. We collect all this information in our methadone database.

    Methadone is an excellent analgesic. We have also developed an educational workshop for the use of methadone as an analgesic. Methadone is cheap and it works very well. Physicians are learning that this is a very good drug, particularly for people with large analgesic requirements who have gone through a lot of the other potent narcotics, which are no longer effective. Methadone very often will do very well.

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    We've been working for some time with a drug company, Schering, to bring a new drug, buprenorphine, or Subutex, into this treatment program, because we feel that a small number of methadone patients do not do well on methadone and may benefit from a buprenorphine program. It's extremely important, we feel that when buprenorphine is approved by the health protection branch in Ottawa, it be approved under the umbrella of a methadone program, so that it requires special authorization, and thus special training and special monitoring. I was concerned a short while ago to learn that the health protection branch here in Ottawa was considering approving buprenorphine as a regular drug. I have explained to them it that I think this would be a big mistake. It has the potential to destabilize methadone programs across the country, and I think it could lead to deaths. I appeal to you as a committee to talk to the health protection branch. If they consider doing this, I think it would be a big mistake.

    Thank you.

    The Chair: Thank you very much, Mr. Hickey.

    Dr. Brian Taylor: Madam Chair, may I make a closing comment on behalf of us both on a concern of our college?

    The Chair: Sure.

    Dr. Brian Taylor: This committee, as I understand it, has a focus today on the diversion of prescribed drugs. That problem, I understand, is one you are considering, at least in part, today. One real concern for our college, and I think across Canada, is the fact that Internet prescribing is taking off big time. Once physicians are able to prescribe and pharmacists are able to dispense using the Internet, it will be impossible to monitor, at least in a meaningful way. Of course, because it will be on the Internet, there will be no boundaries. Already Internet prescribing is occurring whereby U.S. patients are accessing cheap Canadian drugs. In our province the use of the Internet will bypass the PharmaNet, which has become the skeleton upon which we've built our programs. I think Internet prescribing will only facilitate diversion of prescription drugs to improper use. That's something your committee might wish to address and consider.

    Thank you.

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    The Chair: Thank you. You are the first person to bring that up--one more thing we have to deal with. We weren't even thinking about prescription drugs, and when we started, it was actually in Vancouver where someone raised the issue with us. Our initial reaction was, what? But as we went across the country, particularly in the Atlantic provinces, we saw clearly that the scope of the problem is quite large, so we'll put that into the mix.

    Thank you both very much.

    Now, from Nova Scotia, we're very pleased to have Coleen Conway.

    Ms. Coleen Conway (Manager, Prescription Monitoring Program of Nova Scotia): I would like to thank the committee for inviting me to come here this afternoon to represent the prescription monitoring program of Nova Scotia.

    As the committee is aware, I think, we have a larger problem with abuse and diversion of narcotics and controlled drugs in our province than we do with illegal street drugs, such as cocaine and heroin. The prescription monitoring program attempts to look at preventing the abuse of narcotics and controlled drugs in our province. Our program is quite different from those of B.C. and Saskatchewan in the way it's administered. I will attempt to review our program and talk to you a little about some of the issues we're facing in Nova Scotia at present with our program.

    In 1992, a group of key stakeholders came together on the issue of the abuse and diversion of narcotics and controlled drugs in our province. They developed what we call PMANS, the Prescription Monitoring Association of Nova Scotia. The mandate of PMANS is to eliminate the abuse and diversion of a panel of prescription drugs, narcotics, and controlled drugs that are listed under the federal act. This group of key stakeholders is felt to be an unbiased group, because each of the members has a stake at hand.

    The prescription monitoring association is made up of a number of voting members. There is representation from the College of Physicians and Surgeons of Nova Scotia. There is also representation from the medical society, the provincial dental board, the provincial dental association, and the pharmacy association, as well as the college of pharmacists in Nova Scotia, which has had a recent name change. We also have non-voting members in our association. They consist of the Nova Scotia Department of Health--and the program is funded by the Department of Health in Nova Scotia--drug dependency services, who are our addictions people in the community, and Health Canada. We also have resource people. The resource currently is representation from the RCMP in Nova Scotia.

    The mandate of the prescription monitoring association, the work the association does, is to develop policy guidelines in relation to the program. They also have a working committee known as the program's operations committee. That committee is basically a peer review committee. Cases are referred to this committee and examined, and then interventions are recommended, either from an educational point of view, whereby an educational strategy may be implemented, or by referring the case to the various professional bodies. For instance, a physician may be referred to the college of physicians and surgeons or pharmacists may be referred to their college.

    That program operations committee again is made up of all the key stakeholders, representation from the college of physicians and surgeons and the medical society, as well as the pharmacy groups and the dental groups. We also have a part-time medical consultant who works with the program. He also sits on the committee, as I do, but both of us are non-voting members.

    The program is managed by Maritime Medical Care, which is a subsidiary company of Atlantic Blue Cross Care. We have staffing of four customer services representatives, an administrative assistant, a medical consultant on a part-time basis, a programmer, and me.

    We serve approximately one million Nova Scotians and over 2,000 Nova Scotia physicians. We also serve approximately 50 New Brunswick physicians--there is some cross-border shopping between Nova Scotia and New Brunswick. Those physicians from New Brunswick who reside or practise close to the border of Nova Scotia are encouraged to register with our program, so they can glean the benefits of it.

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    We also have approximately 500 dentists registered, about 300 pharmacies, and over 1,000 pharmacists. We also serve both methadone programs in the province. Drug dependency services have a methadone program and the low threshold program, which are both located in the Halifax-Dartmouth region. We wish we had provincial access. That would be nice.

    Our program revolves around the triplicate prescription. We are not as fortunate as B.C. in being on-line and having our prescriptions automatically captured, so we use data entry clerks for that. All prescribers in the province who want to prescribe any narcotic or controlled drug must register with the program. Once they register with the program, they receive the triplicate prescription.

    There is an example in one of the PMANS bulletins of what the prescription looks like. It is like a personalized cheque book. The physician or dentist registers with us, they are issued the triplicate pad, then we issue the pads with the corresponding physician's name, address, and registration number, as well as personalized pad numbers, like cheque book numbers, so that the prescription can be traced.

    There are three copies. When the patient goes to the prescriber and a prescription is written, one copy is kept by the prescriber. The other two copies go with the patient to the pharmacy where the medication is dispensed. The pharmacist keeps a copy. The third copy comes to us for data entry. Under their act, pharmacists are obliged to send our copies of the triplicate scrip every seven days, so there is some delay in the timeliness of our data. We are looking at a two-week delay sometimes. We receive approximately 300,000 scrips a year, and we process about 24,000 scrips every month.

    What do we do with the data we collect? We generate a number of different reports. One is called the double-doctoring report, whereby we look at patients who have seen three or more prescribers in a 30-day period. We issue what we call alert letters on those particular patients to those prescribers. We send out approximately 2,000 letters a year on approximately 400 patients. We have done some evaluation on the effectiveness of the alerts and have noted that there is a 60% decrease in the number of prescribers seen after an alert letter has been issued. It does seem to have some impact.

    We also generate a report on what's called an excess threshold, or, as Dr. Taylor mentioned, high usage. We take a look at those prescribers who are prescribing over what the program has set as the various drug thresholds. We send a letter to the prescribers asking for an explanation of the medical indications as to why they have prescribed the amounts they have prescribed. We send approximately 240 letters a year to prescribers. We have also done an evaluation of that intervention and have noted that there is a decrease of approximately 40% in the numbers of prescriptions written after a letter has been sent. That doesn't necessarily mean this is a good thing either. We can talk a little more about that later on.

    We also do what is called peer comparison. Last year we did an analysis of codeine prescribing in the province and sent prescribers their own profiles. We actually linked up to Dalhousie's continuing medical education to develop an educational initiative with this report or mail-out. We're hoping it's going to be seen positively by physicians in the province. If the physicians do examine their own profiles and partake in this mail-out, they can receive continuing medical education credits too, so that is a motivation for the prescribers to actually look at and assess their own individual prescribing patterns.

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    We also provide information to researchers within the community. We offer patient profiles, for example, to practitioners. They can call our office or write to us, and we can provide patient profiles to them. For instance, if somebody in an emergency department has a patient and they are wondering if they are drug-seeking or if this is legitimate, they can call us and we can give them the appropriate information. We also provide information to law enforcement, but that's only based on the availability of a search warrant. We also provide information to the various professional groups, for instance, the College of Physicians and Surgeons, the Medical Society, and the provincial dental board.

    I'm not going to get into the disclosure policies. It is a problem for us, and we can talk a little bit more about that when I talk about some of the issues the program faces. Bear with me, and I'll flip through them.

    There are two major issues for Nova Scotia. One is the limitation with our computer system. We're not as fortunate as B.C., we're not on-line, and we would like to be on-line. It would certainly improve the program immensely and provide more timely data. Our system is quite outdated. It's a stand-alone system. It doesn't interact with anyone else's system, so we can't thoroughly evaluate the data. We lack automation for interventions we can capture. We can't evaluate our interventions appropriately. We have secondary capture of our data, meaning that it's entered manually. So there's always room for error because of the manual data entry. We have very limited data reporting and viewing. Only fixed reports can be gleaned from the system. Of course, it's not as timely as we would like. It cannot support expansion. For instance, we would like to monitor benzodiazepines, but we're afraid that if we started to do that, our system might explode. Unfortunately, we are not equipped for that as yet. The Nova Scotia Department of Health is looking into the situation, and hopefully, we'll see a new system sometime soon.

    There are other issues with program evaluation, including examining the effectiveness of the prescription monitoring program and being able to link with other databases so that we can determine the impact.

    I think Dr. Taylor alluded to the issue of inadvertent outcomes or surveillance, that somehow we affect the practices of the prescribers in a negative way. Our alert letters and explanatory letters are not sent out, for instance, on palliative care patients or patients who have cancer. We're hoping there are few inadvertent outcomes from our program because of that.

    We also lack the authority to act on the data we have. Currently, the province is looking at either developing a separate piece of legislation for prescription monitoring or incorporating it under other existing acts, such as the Medical Act, the Pharmacy Act, and the Dental Act.

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

    While one of you was speaking, we were pleased to see Dr. Kendel arrive from Saskatchewan. You've given us copies of your presentation in English, so they are available on the table should anyone wish one. Welcome.

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    Dr. Dennis Kendel (Registrar, College of Physicians and Surgeons of Saskatchewan): Thank you very much. I apologize for being a bit late. It's difficult to get here by two o'clock from the hinterland of Saskatchewan. But Air Canada was actually on time--

    The Chair: We'll mark that down.

    Dr. Dennis Kendel: --so I didn't miss too much.

    I spoke with my colleague Brian Taylor earlier and understand that he has explained to you in some detail the mechanics of the triplicate prescription program. I'm not going to dwell on that, because our triplicate prescription program is not dissimilar to that in British Columbia. Saskatchewan was the second province in Canada to introduce such a program, in 1988. It's interesting that part of the impetus for us to introduce such a program was what occurred in the preceding year. In 1987 there was a massive RCMP investigation of multiple doctoring, which resulted in 130 citizens being charged with offences under the Narcotic Control Act as it then existed, and 11 physicians were referred to us for investigation, and sanction in many cases. It was probably that experience more than anything else that galvanized our attention so we would try to move upstream to see if we could do more to have early intervention or prevention of this problem.

    I'd like to talk to you today primarily about some of the values we think are important to consider in dealing with this societal problem.

    First we need to talk a bit about the nature of the problem. Misuse of prescription drugs is not limited to the panel of drugs you are talking about here today. Of course, there's misuse of antibiotics, and that has a detrimental effect on the patients who use them, because they are exposed to the risk of the drugs without any countervailing benefit. Widespread use of antibiotics encourages the emergence of antibiotic-resistant strains of bacteria, which we then can't treat effectively. So it puts the whole population at risk of disease.

    But for a long time now we have had a view that there is a special category of drugs, those that are dependency-inducing, that do need to be treated with even more care, because their abuse and diversion has even more potential for societal harm. It's important to recognize that chemical dependency is a disease process itself. People who are chemically dependent are incredibly driven to get access to their drug of choice. If it's a prescription drug they use, they will use incredibly devious means to actually get the drug.

    In the past, when the RCMP have done investigations and apprehended certain information under search warrants, we have seen maps drawn by people who are going to go double-doctoring. They time their visits so they may visit 10 clinics in a day. Given the waiting time in some family physicians' offices, you might wonder how that's possible, but they know which walk-in clinics and other clinics are likely to give them quick access. They can literally hit 10 doctors in a day with a very sophisticated story of having lost their drugs, flushed them down the toilet, the dog eating them, or whatever, and they do get an enormous amount of a drug.

    There are many agencies, obviously, that have an interest in this, including, clearly, the federal and provincial health ministries, the departments of justice, and of course, professional regulatory bodies, such as the College of Physicians and Surgeons. I think many people look to the College of Physicians and Surgeons to try to deal with this problem, because if we're talking about the inappropriate use of prescription drugs, every prescription drug has to begin with a physician prescription. As nurse practitioners get prescriptive authority in some jurisdictions, it will occur with nurse prescriptions as well. It's tempting to use simplistic logic and say, if we could just control physician prescribing better, this problem would go away.

    I think we have to be somewhat cautious in our zeal to stamp out the problem. Certainly, we have to be careful that in excessive zeal, we don't compromise the appropriate use of these drugs. I gather from comments I heard from Coleen that Brian has talked about narcophobia and some of the dangers of creating too great a fear about the use of some of these drugs, so that they aren't used in adequate dosage and when they are indicated. That's an important societal consideration. We also have to be mindful of the privacy rights of patients, and we're very aware of that. Finally, we have to be mindful that if we instil in physicians too great a distrust of patients, so that they're seeing every patient as a possible misuser of these drugs, we will compromise the doctor-patient relationship, which is very important to therapeutic effectiveness. So we mustn't demonize patients to the point where doctors are looking at everyone as a possible problem.

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    You well know that in the justice system there's a philosophy that it's better that a few people who are guilty of a crime go free than that some people be wrongly convicted and incarcerated. I'd suggest the balance on this issue is that we will always have to accept some abuse of these drugs and not overreact in such a way that we actually cause societal harm from our overzealous approaches.

    With the approach to this societal problem, historically, Health Canada has always put these drugs in a special category and more carefully controlled their use and monitoring. Way back in history Health Canada's Bureau of Dangerous Drugs, as it was then called, used to generate data for us about the misuse of these drugs. The problem is that the data were so late in coming, usually at least six months after the fact, that they were almost of no value for really intervening in preventing the problem. Their only use really was to prosecute physicians sometimes who had demonstrably unacceptable prescribing practices and were refractory towards education. So the fundamental goal of triplicate prescription programs was to get more timely access to data we could, first, share with physicians to try to prevent the problem and, second, use ourselves to modify prescribing practices where we thought those were inappropriate.

    But triplicate prescription programs no longer represent the state of the art. The very mechanics of having to carry a separate prescription pad often mean that post-operative patients don't receive adequate analgesia. Surgeons seem to be incredibly resistant to actually carrying these prescription pads. We thought about issuing holsters whereby they could actually carry them at their side, but they didn't go for that idea. These pads are personalized, as Coleen has pointed out. They're like your personal cheque book. You can't pass them between physicians. They aren't usually available at sites where post-operative analgesia is prescribed, so people go home without adequate analgesia or they phone their family doctor, who had no awareness of the surgery going on that day, and it causes some problems.

    Clearly, the way to go in the future is, through IT solutions, to have immediate on-line access to this information. All of us are incredibly envious of British Columbia, where the PharmaNet program has given the regulatory bodies for medicine and pharmacy access to that information comprehensively and is intended ultimately to bring that information to front-line physicians as they practise medicine. It hasn't achieved that yet--it's in the pilot project stage--but we understand that's the goal. We understand that's the goal of the so-called Wellnet program in Alberta, and it's the goal of the Saskatchewan Health Information Network. But it's still some way down the road.

    We would envision in the future that as physicians attend individual patients, they will have on-line, real-time access to the complete drug use history of that patient. It would be axiomatic that the physician would have the right to that information as a condition of treating the patient. As I'll mention later on, we appreciate that there ought to be an implicit understanding that in securing health care, citizens would have their physicians gain access to that information. We would not favour very cumbersome consent processes, because we would point out that the patients who are inclined themselves to misuse these medications or to divert them to the street are not the people who are going to readily give consent for access to information that discloses their illegal activity.

    The professional regulatory bodies in medicine and pharmacy will also need accurate and comprehensive on-line access. In Saskatchewan we have been working towards that goal. Indeed, our provincial government just enacted legislation that will give us unfettered electronic access to prescribing data for all persons under provincial jurisdiction.

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    But as you know, there's this jurisdictional problem in Canada whereby health care for first nations people is a federal responsibility. Regrettably, the interpretation and application of federal privacy legislation, in our opinion, is a real barrier to effectively dealing with this problem. Health Canada has taken the position that they will have to actually obtain consent from each individual first nations person in order to use first nations prescribing data for some of these public health objectives, such as preventing prescription drug abuse.

    You have probably heard some of the details of that program. Frankly, we think that program is unworkable, simply in the logistics of actually getting consent from each patient and then asking yourself how enduring that consent is and how often it has to be renewed. What happens if people don't give their consent? I was told by a person at Health Canada that if the person didn't give their consent, they would deny benefits to the first nations person under the non-insured health benefits program. Well, I would like to see the first court challenge to that, because I don't think leaders of aboriginal people would accept as a solution the fact that if you don't give consent, you don't get service.

    We hope that Health Canada will change its policy. We realize it has been driven largely by legal advice, but we think there are times when the balance between privacy and the public good has to be reconsidered. Frankly, the disease of chemical dependency is one in which you fundamentally have to override some privacy rights, not only to help the person who is chemically dependent, but also to prevent harm to the greater society at large.

    So in fact, if we could get in place across the country a system such as PharmaNet, which now exists, along with bringing it to the actual coalface where physicians practise, they could prevent a lot of the problems immediately. As you have probably heard from Dr. Taylor, the system in B.C. is literally current to the prescription filled 30 seconds ago. The potential to move quickly from office to office and to scan prescriptions simply does not exist, whereas in a system even such as that Coleen described, where there is a two-week delay, a sophisticated multiple-doctorer can collect thousands of pills in two weeks, so even that delay is really inhibiting the effective prevention of the problem.

    I made reference in my paper to a death in Saskatchewan involving a first nations man, Darcy Ironchild. Darcy died from an overdose of chloral hydrate, which is a hypnotic, or sleeping pill, and is not in the panel of drugs that we monitor in our program. As Coleen pointed out, most computer systems that are just vested in college offices or even in the Atlantic Blue Cross organization are not powerful enough to manage the whole spectrum of drugs, so we just monitor the narcotic and controlled drugs. Darcy Ironchild actually managed to collect 300 different prescriptions from various doctors in a matter of less than a month. He was consuming a huge amount of this drug. Of course, drug addicts sometimes mistake their tolerance and on one occasion take too much and die as a consequence.

    Darcy Ironchild's family reacted very angrily and said, where was the college of physicians and surgeons? They asked what we had done to try to prevent such a tragedy. While we had enormous sympathy for the family, all we could say is that unfortunately, we had no awareness of Darcy Ironchild's drug use and tso had no potential to intervene. If we'd had comprehensive systems, however, in which the benzodiazepines, the hypnotics, and all these drugs were accessible for monitoring, we likely could have done something to prevent this death. In the wake of the coroner's inquest into this death, we are working with our justice department in Saskatchewan and SaskHealth to try to build a more comprehensive system such as that which is emerging in British Columbia, but the federal jurisdiction issue with regard to first nations people is still a bit of a barrier.

    What I have asked people is this. If this is a nation, how is it that in British Columbia PharmaNet can collect data from all people, irrespective of their race, ethnicity, or cultural heritage, but in the rest of Canada there is this divide, where there seems to be a different policy for a part of our population compared with the rest? Usually, the answer is that it's a legal question and it just depends on how provincial and federal governments have jigged their legislation. Clearly, the legislation in British Columbia empowers the government of that province to collect and use data in a way that other provinces haven't yet got their minds around. We would hope that across Canada this problem will be addressed in a similar way, and IT solutions are really at the heart of the solution.

    Those are the things I want to share with you. Like my colleagues, I certainly am very keen to answer questions you might have. Thank you very much.

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    The Chair: Thank you, Dr. Kendel. Thank you to all the panellists.

    As was mentioned earlier, this is an area that crept up on us. As we travelled across the country and saw the different systems operating in different places and listened to people yesterday, we clearly heard the message that it would be nice to have one national system that everyone could plug into in real time, especially in some of those border communities. Giving us a description of what you're doing to try to intervene has been really helpful.

    I'll turn to my colleagues for questions.

    Mr. White.

    Mr. Randy White (Langley—Abbotsford, Canadian Alliance): Thank you, Madam Chairman.

    Thank you all for coming such a long distance for what is really a relatively short time before a committee. But I can assure you that things you said here will affect some of the recommendations we have. Although it is a short time, it is an important time.

    I'd like to ask one of you or all of you, the most knowledgeable here, where the bulk of the legal prescription drugs are coming from. Do they come from various doctors' offices? Are they stolen from doctors' offices? Are they obtained by faking an illness? Are they stolen from the manufacturer? Are they stolen out of homes? Where is the bulk of this coming from?

    Dr. Brian Taylor: Mr. White, you are referring to the drugs on the streets?

    Mr. Randy White: Yes.

    Dr. Brian Taylor: They are usually legitimately prescribed drugs that are then diverted. For example, Tylenol 3, which is a fairly readily obtained drug, acetaminophen and codeine, is very common currency on the streets, as I understand it. I've spoken to members of the Vancouver drug squad. I don't think the enforcement agencies have a very clear handle on the use of prescribed drugs on the street. I think they well recognize that certain drugs have a very real market value and are used to obtain the real drug of choice or to supplement it, but I don't think society has a clear understanding of just how much prescribed medication is circulating on the streets, certainly in our province.

    Dr. Dennis Kendel: I would like to add some comments to those offered by Dr. Taylor. Certainly, the overwhelming proportion of prescription drugs that make it to the street came through legitimate physician prescriptions. There may be some theft, but I think that would be very rare. Pharmacies are broken into, but that probably doesn't net a huge amount of drug that's diverted. Appended to my document is a copy of the presentation I made to the House of Commons Standing Committee on Public Accounts about a year ago. I describe in there three types of physicians we regard as contributing to this problem.

    First, I want to point out that very competent and thoughtful physicians can be duped from time to time by people who masquerade with a certain illness or tell a very heart-wrenching story. People in society today are very mobile, so many people are travelling across the country. They need medications at the time, so they present to a doctor and often get medications on the basis of false information. But there are some physicians who are too easily duped, and our educational challenge is to help physicians understand that there are certain things in a patient history that ought to trigger suspicion. I made a somewhat joking reference to them, but it isn't really a joking matter. There is the frequency with which some people say, I lost my medication, or, it slipped down the toilet. Those things can happen to real people sometimes, you can knock your pills down the toilet, but it shouldn't happen very often. There are certain things that should be red alerts to physicians that they ought to resist the inclination to prescribe.

    Then there is a cohort of physicians we characterize as having failed to place adequate limits on the size of their practice. They are seeing too many people per day. This is in a fee-for-service system. Quite frankly, if you don't take enough time to interact with each person, it's more likely that you are going to make mistakes. Also, issuing a prescription is a very quick way to terminate a doctor-patient relationship. So doctors who actually engage in a very high volume practice, generally for self-interest reasons, tend to offend more. Again that's a regulatory problem, and we need to deal with it.

    Then there is a very small cohort of doctors who actually exploit the system themselves by knowingly prescribing drugs to these people. They get their licences revoked. Those people don't even have to multiple-doctor, because they can get all the drugs they want from one source. Fortunately, when you have systems such as have been described here, you pick up that pattern of prescribing with physicians, and you can do something about it from a regulatory perspective. The interesting thing, though, is that if your scope of monitoring is narrow, then just like the drug-seeking patients who decide to look for drugs outside the system, the unprofessional physicians will prescribe outside that scope. So they will simply prescribe benzodiazepines. Therefore, you have to have comprehensive monitoring so that you can detect physicians who are acting highly inappropriately.

    So those would be the three areas of concern to us.

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    Mr. Randy White: I'm glad you answered that as well, because as a CEO of an organization of some 2,000 employees at one time, one of my biggest difficulties was trying to get the doctors to understand that their letters to us on behalf of employees saying employees should have six months off for stress, or they had sore fingers, or they should be off for an unlimited time were just a real problem. There was no consistency at all in that whole area among the medical profession, and it was costing my organization a lot of time off. I can imagine that the stories they were getting for those kinds of things were probably light compared to the stories they get from people who are trying to get drugs from them.

    On the characteristics of methadone, must individuals who are receiving methadone receive it for the rest of their lives. Or is there a duration to this? I've heard both stories, that they will always have to receive it, I have to run my methadone clinic here for a long time, and every time I get somebody, I need more people, while others have said, no, that's not the case. What is the case?

    Mr. Peter Hickey: I can answer that. We recognize heroin addiction as a disease such as diabetes. We don't have a problem with diabetic patients taking insulin for the rest of their lives. The answer to the question is that a patient should receive methadone until such time as he can come off a methadone program. It may very well be that he would receive methadone for the rest of his life, and if he's appropriately treated with methadone, there is no downside to that.

    Mr. Randy White: Fair enough. There are methadone treatment centres that some label low threshold. Others are labelled high threshold and various degrees of threshold. In fact, the committee and I were in what I guess was a low threshold centre. One of the addicts there told me and one of my colleagues here that he gets his methadone, but also every day he has to have a couple of joints, a few Tylenol, and something else he had to supplement. I thought, wait a minute, there's something wrong with this picture. You're in here trying to get off, but you're still using drugs, everything but heroin, I guess. I'm wondering about this concept of low threshold and high threshold. Does it work? Is it a sensible process, or should it really be that you're on methadone and you won't get methadone unless you stop taking the other things? It's high threshold, I guess.

    Mr. Peter Hickey: You're correct: there are high threshold and low threshold programs. I think there has to be a mix of programs. The idea is that methadone programs are run from a harm reduction approach, so you have to look at the patient. Is the patient benefiting from a methadone program or not? If some patients are receiving methadone in a high threshold methadone program, smoking marijuana, and using something like Dilaudid or whatever, that's a challenge for the treating physician. These people have substance abuse problems. That's a part of the treatment.

    We can look at some patients in the downtown east side of Vancouver who have not a roof over their head, no means to support themselves, and very poor health. To engage those patients in a low threshold methadone program where they are using needles less often, perhaps using less marijuana, less street drugs, or whatever, is that harm reduction? Yes, that's harm reduction, and that's a low threshold program, but the physician still has to reassess that patient and ask, okay, are you benefiting from this program or not? Some of those patients may very well be discharged from a program, so you have to constantly evaluate: is the patient benefiting? Yes, they are still using, but they are using less often, and maybe they are sharing needles less often. Is that a benefit? Definitely, it's a benefit.

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    Dr. Brian Taylor: Mr. White, if I may, I think it's important to remember that addiction is a relapsing disease. Because somebody has started using narcotics again, it is not a reason to abandon treatment. I think you have to redouble your efforts in treatment and understand that all addictions, alcohol or drug addictions, are relapsing diseases, and repeated use of the drug of choice is certainly very common.

    Dr. Dennis Kendel: I just want to make one other observation. Often within society at large, and even within the medical profession, there's still this considerable variance in attitude towards harm reduction philosophies. For example, in Saskatchewan, where we haven't yet had success in developing as comprehensive a methadone program as British Columbia has, but are moving towards that, we've had a struggle in different policies between our federally controlled and provincially controlled penitentiaries or jails. In one of them there is an acceptance of the fact that you might start somebody on a methadone program while they're incarcerated, while the other, the provincial jail, which is what I'm talking about for the moment, had a policy that if you were on methadone when you came, we would continue it, but we would not consider starting you on the program, even if a physician evaluated you and suggested that would be a logical thing to do. Using Peter Hickey's example, that would be about as rational as saying that if somebody develops diabetes after they are incarcerated, we're going to let them just die of their diabetes, we're not going to give them insulin.

    It's interesting that in this situation the policy was driven, frankly, by the fact that the penitentiary was relying upon the services of a physician who was very opposed, from a moral perspective, to harm reduction. Therefore, that physician's policy was affecting all the inmates in the penitentiary. I think that at a regulatory level, we, as colleges, have had a struggle to say that just because you get incarcerated, it doesn't mean you lose all your options for medical services that people would get out in society at large. Therefore, we've had to sometimes try to arrange--

    Mr. Randy White: Methadone is sold in prison.

    Dr. Dennis Kendel: --that there's a balance of advice to the penal institutions, that it isn't all one-sided.

    Mr. Randy White: Are you aware that methadone is sold by prisoners in prisons?

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    Dr. Dennis Kendel: Oh, prisons are a hotbed of illicit drug use. You can probably get virtually any drug you want in a penal institution. That's not a surprise to us.

    Mr. Randy White: I have another question that I want to deal with regarding the qualifications of people working in rehabilitation centres, needle exchanges, and those kinds of areas. Across this country I've seen everything, from buildings that were much less than sanitary to individuals whose basic qualification was that they're drug addicts or ex-addicts, but still addicts, I guess. There doesn't seem to be any consistency whatsoever across this country. I don't know whether there is in each province, but there certainly isn't across this country. Is that a concern you have? Even in methadone treatment centres, the qualifications of the individuals running them vary so much.

    Mr. Peter Hickey: I can't speak to the qualifications of the people in needle exchange or the counsellors. It's certainly not our mandate. The qualifications of methadone prescribers are certainly very high. As I mentioned, one of the objectives of our program was to increase the quality of care and standards of prescribing. As for the hurdles a physician must go through, which I illustrated some of in my presentation, they're very stringent. We have the only training program of its kind in North America. The physicians are very well trained with regard to methadone prescribing. As I say, I can't speak about some of the other people.

    Mr. Randy White: It's not always doctors. It is nurses as well that are in some of these centres. I'm not questioning the qualifications, I'm asking whether or not you think there should be minimum standards for all these facilities across the country.

    Dr. Brian Taylor: I think it would be difficult to argue against that. Certainly, people who are caring for persons with addictions should be well qualified. I think there should be a rational approach. You mentioned the needle exchange program, for example. When it was first introduced in British Columbia, the needle exchange program had a limit on the number of needles that were issued per person. If somebody is using heroin eight times per day, it doesn't make much sense to give them six needles per day. It doesn't make any sense at all, and yet that was how the program was introduced.

    So I think you're quite right, Mr. White. I think there should be a rational approach. I think the people who care for these sick folks should be well qualified, and our college has done its bit, I think.

    Mr. Randy White: Thank you.

    The Chair: Now we'll have Dr. Fry.

    Ms. Hedy Fry (Vancouver Centre, Lib.): Thank you very much. I just wanted to ask one small question.

    I think you all gave very comprehensive presentations. One of the things that concerned us as we travelled across the country was that we found, as I think you've explained here quite well, that in some provinces it is easier to get prescriptions from doctors and you can sell them on the streets. In other provinces it is more difficult to do so. You have explained to us that it obviously depends on the timeliness, the access, etc. of the triplicate program. However, what we found is that in one province the methadone program was given out so that some people could just go to the drugstore and get methadone. They could take a prescription and get it from the drugstore and eventually almost have repeat prescriptions, where they could just go to the drugstore, so they never saw a physician at all to monitor them on a regular basis.

    I want to know what you think of that and whether you feel there is a slippery slope in that and some danger, in that all you did was give out methadone without the accompanying comprehensive approach to treating substance abuse, which would automatically come with going to a physician or a clinic to get your methadone.

    Mr. Peter Hickey: Certainly in the British Columbia program, the vast majority of patients receive methadone from a pharmacy--that's a given--as a daily witnessed dose. The pharmacist is a vital part of the methadone program. He is the eyes and ears of the physician. For instance, if a patient shows up and isn't doing well or if the patient doesn't show up for their daily dose, we would expect the pharmacist to contact the treating physician and say there may be a problem with that patient. There should be a good interaction there.

    Through our audit process, we would not expect a physician to issue a prescription only and not see the patient. That would be very obvious in the audit process through the clinical record. Those are things that certainly we would look for and pay a great deal of attention to. That would not be acceptable. Methadone treatment is not getting a scrip and going to get methadone. There are a whole lot of other aspects to it as well.

    Ms. Hedy Fry: It is obvious that British Columbia has this sort of best practice going on right now, but it wasn't in British Columbia that we heard about this. We also heard that certain pharmacists were telling methadone users to bring their friends to their pharmacy, and there wasn't always the witnessing. I just wondered if you know of that in other provinces and if there is anything you can do or you can suggest we do, mainly because, as a federal government, we don't have the authority to make these kinds of decisions. They all come from professional bodies. What would you see as a solution to that?

¹  (1540)  

    Dr. Dennis Kendel: One would want reasonably uniform standards across the country in all areas of health care. Sometimes I think the reality we struggle with is that it's often easier to deliver uniform solutions in areas of high population concentration than it is in very sparsely populated parts of our provinces. For instance, when Peter talks about every citizen in B.C. having access to methadone for harm reduction purposes or palliative care, we can't yet say that in Saskatchewan, because we don't have physicians authorized to prescribe it in every community. We feel strongly that it is so important to have adequate standards. If there isn't a physician who is adequately trained and authorized to prescribe it, then unfortunately, for the moment there is uneven access.

    We wouldn't say that there should be a throwing aside of the standards just in favour of access, but on the other hand, if you regard this as an integral part of health care, I think there is some imperative to try to make it reasonably accessible to all people. You might have to use somewhat different strategies in some parts of the country or in some provinces because of demographic differences. For instance, when you think about the far north, you probably couldn't use exactly the same strategies as you would in the southern part of the country.

    Ms. Coleen Conway: We have problems in the Maritimes with having enough physicians who are licensed to prescribe methadone to addicts. I know, with the methadone programs in Halifax, there are patients moving there from New Brunswick and from Newfoundland just to get their methadone, which I think is horrendous. I wouldn't want to leave my community because I required methadone. I think there needs to be a national strategy for delivery.

    The Chair: Mr. Lee.

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

    I want to congratulate the medical group from B.C. for managing several thousand methadone maintenance programs, which is a benefit.

    I want to ask a real off-the-wall question first. We move a heroin addict from heroin to methadone. Why not just leave the addict on heroin?

    Mr. Peter Hickey: That's an interesting question. As you are probably aware, British Columbia is in the process of a heroin prescription trial. It's already been done in Switzerland. Basically, it doesn't work to leave a patient on heroin. For one thing, heroin has a very short duration of action. As Dr. Taylor mentioned, you may have somebody shooting heroin six or eight times a day. It's pretty hard to lead a productive life if you're having to go somewhere and shoot heroin six or eight times a day.

    Again, part of the problem with addiction to heroin is the actual use of needles. As you know, we've got a huge HIV epidemic. Sharing needles is largely responsible for that. One of the objectives of methadone is to get a patient off IV drugs, away from needles, away from needle sharing and get them onto an oral medication they can take once daily, which is what methadone maintenance does, allowing them to get on with life. We've got a lot of very productive citizens taking methadone as a carry privilege, where they get a week's carry. They can go home, and you probably would not even know they were on a methadone program or have a dependency problem.

    Mr. Derek Lee: That's an excellent answer. Thank you. We did have the benefit of seeing heroin dispensing in Europe. One or two of the European countries do it now. I wanted to get that on the record, because the question may come up.

    I also wanted to look at the Saskatchewan situation addressed by Dr. Kendel. I took a look at the October 2001 letter from a Mr. Cooney at Health Canada, first nations and Inuit health branch, which I thought was a lousy, inadequate, non-cooperative response to the letter from Dr. Kendel, who was merely seeking partner participation in an effort to prevent the double-doctoring and the diversion of prescription drugs in that province. I wanted my remarks to show on the record in that regard.

    Why is it that this problem doesn't appear to exist in British Columbia, when it appears to exist still in Saskatchewan. Does anyone know the answer to that?

¹  (1545)  

    Dr. Brian Taylor: We've addressed it in several ways. In the first instance the Pharmacy Act in British Columbia requires the pharmacist to directly review the prescription profile before dispensing. Therefore, you have that one professional obliged by his regulatory body to perform that review.

    When we put the PharmaNet data base in the emergency departments, we had that whole process reviewed very carefully by the Privacy Commissioner, and it was agreed that a notice be put in the emergency department indicating that the PharmaNet profile was going to be reviewed as part of the treatment process. The patients were informed in that way.

    In addition, in the PharmaNet program it is possible for a patient to select a keyword that you must provide to the caregiver in order that your PharmaNet profile may be reviewed. So without the provision of the keyword, the person may not see it. In our experience, the keyword has been used by less than two per cent of the population, and in addition, those who have it provide their keyword to the pharmacist for convenience. So it's not a big issue with patients. Most patients who go to see a physician would like them to know what drugs they're taking, in simple terms.

    Mr. Derek Lee: I was just trying to see my way to understanding how the federal government could better cooperate in assisting the Saskatchewan professionals to better manage the risk of diversion of prescription drugs. It's unacceptable that the federal government wouldn't. If they're not prepared to lead in a national solution, they'd bloody well better be a partner with each province as each province tries to solve the problem. And if they're not, they're not doing their job.

    Maybe the federal reply here was simply covering up the fact that they haven't got the information to share, they don't know how to do it, and they haven't got a budget to figure out how to do it, and they're simply saying, the Privacy Act doesn't permit us to do this, when the real reason is that they haven't got any idea how they would do it anyway, because they haven't got their own database, information, or mechanisms to share info.

    Dr. Dennis Kendel: I'd like to explain what I understand to be the jurisdictional conflict here. In delivering health services to first nations people, it is interesting that there are two different models. One is in relation to securing physician services. For instance, first nations people go to doctors and secure services the same as everybody else. Those services are paid for by provincial payment agencies, and then there is an arrangement between the federal and provincial governments by which there is money exchanged. I don't know how it works, but there is some formula, and it works.

    It is interesting that to fulfil the societal objective of making sure doctors aren't ripping off the system, because every province has a program in place to retroactively evaluate physicians' billing practices and, where necessary, recover money, that system treats aboriginal and non-aboriginal people equally. When we see these profile reviews, there is a mixture of people, because everybody agrees that there needs to be the same monitoring system, where the non-insured health benefits, NIHB, program is uniquely a federal program and guarantees to aboriginal people a range of drugs that exceed what many other citizens enjoy, and therefore it is administered similarly. The interesting thing, though, is that at the point of the pharmacy all those prescriptions go into the computer. All pharmacies are computerized now.

    If we can't obtain the cooperation of the federal government, we may convince our provincial government that at some point the information should be just bled off the computer system, because at one point it all passes through the whole system, but then some of it goes off to NIHB in order to pay those claims. It is all in the same computers, so quite frankly, as you build these networks of computer systems, at some point we may have to say, for societal protection purposes, we will follow the same practices we do in billing review. Since the provincial government had the data in its system at some time, it has some authority to make it available to agencies that enforce certain standards. So maybe the same policy will have to apply in Saskatchewan. In fact, we think that's probably the way we will end up going.

    Because I think one of the goals here is to try to get uniform standards across the country, we still need solutions that work in every province of the country, not just in Saskatchewan. One way or another, we're going to make this work in Saskatchewan, with or without the federal government, but it would be nice if there were a strategy that applied equally across the whole nation. That's what we'd like to see.

¹  (1550)  

    Mr. Derek Lee: Thank you.

[Translation]

    La présidente: Ms. Allard, do you have a question?

[English]

    I have a couple of questions.

    On benzodiazepine, for what is it prescribed?

    Dr. Brian Taylor: It is an anxiolytic group of drugs. They're sometimes used for night sedation, but usually they are for the treatment of anxiety in its various forms.

    The Chair: According to this chart, people in New Brunswick are very anxious, or is there some other--

    Dr. Brian Taylor: On our side of the Rockies we regard that as being secondary to their proximity to the centre of power here.

    The Chair: You have a very dry wit.

    Is there another drug that people in British Columbia, Ontario, and everywhere west--I notice we're on the right side of this story--are using, or is this a category of drug, and so there is just more prescribing of drugs in the east for these conditions?

    Dr. Brian Taylor: I think your latter statement is the correct one. It's a large spectrum of drugs that is used to treat anxiety and like conditions and provide night sedation. The same drugs are prescribed right across Canada. They have the same uses, the same indications. They're just used less per person in our province than they are in New Brunswick, for some reason. Certainly, if we were the college of New Brunswick, we would have some interest in that.

    The Chair: Is it possible that part of this is also due to provincial formularies or reimbursement programs in general? One of the things I think we've figured out about Nova Scotia, for instance, is that Dilaudid, which seems to be used with much greater frequency there, is a generic drug, and therefore is cheaper than some alternatives, and that maybe the Province of Nova Scotia is encouraging its use within the hospital because it's cheap and the province is paying for it, as opposed to other preparations that might be less addictive. Certainly, to go by some of the people we met at the methadone program, the drug is creating a problem. Is there something with what's going on in the eastern half of the country with the formularies or something else that is helping create this dependence? We don't know if it's dependency.

    Dr. Brian Taylor: I think, to be honest, one would have to look at the drug profiles in that province to make a meaningful comment. It's very difficult for us. I don't think it would serve much purpose to have us indulge in conjecture.

    The Chair: Okay, but Dr. Kendel might.

    Dr. Dennis Kendel: It may be a little conjecture. There have been several studies of benzodiazepine use in our province, and there are some things I think are common across the piece. It's interesting that women tend to be prescribed benzodiazepines for anxiety control more frequently, and men drink alcohol. If you look at those two substances in parallel, you will see that often the gender difference is uniform across western society.

    The Chair: And women probably go to the doctor more frequently than men do.

    Dr. Dennis Kendel: Yes.

    The Chair: At least they go every year, hopefully, so they are getting access to it.

    Dr. Dennis Kendel: Women are more likely to actually disclose to a doctor concern about coping with stress or whatever, and men, being rather macho, tend not to disclose those things, so they go and buy their favourite scotch. There are different coping mechanisms.

    One of the things I think is important to recognize is that there is in health services research this thing called small area variation analysis. You will sometimes see huge variation in the way medicine is practised across the country. Increasingly, we would like to see medicine practised on the basis of the best evidence as to what is effective.

¹  (1555)  

    The Chair: Sorry to interrupt, but are you referring to the fact that all of a sudden, you see lots of hysterectomies going on in a certain area?

    Dr. Dennis Kendel: Yes. In all areas of medicine, the difference in surgical procedures can sometimes be three or fourfold when they are age-sex standardized. Within our own province, for instance, we have our own Dilaudid community, Prince Albert. For reasons we don't understand, Dilaudid is prescribed by truckloads in Prince Albert. We have tried to conduct educational sessions there to convince the physicians that there might be a better drug for many of the situations where they are using Dilaudid.

    These patterns of practice get very entrenched. They are often influenced by opinion leaders in the community. They are influenced by the age of physicians, when they acquired their information. When many of us entered practice, people were on amphetamines or on various drugs we tend not to use so much any more. The benzodiazepines were originally held out as being non-addicting medications. Now that's proven to be woefully incorrect, but a lot of physicians still underestimate the dependency-inducing potential of benzodiazepines.

    The Chair: Mr. Hickey, Dr. Taylor, and then I would ask Ms. Conway to comment on that situation in Nova Scotia.

    Mr. Peter Hickey: I think you probably should be aware that as we have already mentioned, the use of benzodiazepines is lower in British Columbia. In most of the other jurisdictions the drug programs, remember, don't pick up benzodiazepines. We do in British Columbia. So that is certainly an important consideration when you see the numbers there.

    The Chair: Dr. Taylor.

    Dr. Brian Taylor: I think the interesting fact displayed by the graph you have is that it's a straight line for each province and for Canada as a whole. The disparity between the provinces is difficult to explain, and I think you would have to look at the drug profiles.

    To my colleague, I would comment that historically, Prince Albert was more responsible for depression than anxiety.

    The Chair: We have to find out exactly what town you live in, so we can give you a little jab there every so often.

    Ms. Conway.

    Ms. Coleen Conway: I really can't explain why there is a larger problem with Dilaudid than in the rest of the country, but I know there are pockets of problematic areas within the province in respect of Dilaudid. For instance, the New Glasgow-Pictou area probably has the most significant problem in relation to Dilaudid compared with the rest of the province, but I don't really know why.

    The Chair: This morning we heard about a process where there aren't information networks to the same degree that you have them in British Columbia and in Saskatchewan, and pharmacists and physicians are establishing phone trees in smaller communities to alert each other to individuals who are trying to scam the system or have a stolen pad or seem to be abusing drugs. I relate that because if people have information or privacy concerns, my goodness, there's absolutely no control on that kind of information sharing and who is exactly receiving the phone call, as compared to an appropriate process of logging in your number and gaining access to someone's patient profile, which would have a check and balance. It did concern us.

    The other thing they raised was that there used to be a system where the federal government, Health Canada individuals, would go into pharmacies and do a check through inspections of the prescriptions and detect patterns of prescription. I guess some of that could be done on-line now much more easily, but they don't do it any more. In the past it helped, especially in small communities, where pharmacists may have had some concern about certain doctors' prescribing habits and didn't want to damage a relationship they need to continue by calling up someone and saying, investigate this doctor, they seem to be having a bit of a problem with benzodiazepine or Dilaudid or whatever. Do you think there would be value in recommending that there be an intermediary from Health Canada who performs some kind of inspection from time to time?

    Dr. Brian Taylor: I guess so, but the real answer, I think, would be to introduce something similar to the PharmaNet program in each province. Currently, at the time of dispensing the pharmacist is obliged to review the drug profile. So he or she can see that this patient received 100 Dilaudid yesterday and will not dispense. Similarly, as we mentioned earlier, we had a pilot project to put the PharmaNet database into every physician's office in our province. Two hundred physicians participated in the survey, it was very successful. The only barrier to fanning it out and making it available to every physician is cost. There is a cost involved in purchasing the software and so on.

    But it makes an awful lot of sense, if you're going to prescribe a drug of concern to a patient, to have a look and see what they've been taking recently and have a clear idea of where they're at with their opioid use. Not only does it address the issue of diversion, it's about good care. It's very important to know this old person who is most certainly dependent on benzodiazepines is receiving escalating doses and to do something about that.

º  (1600)  

    The Chair: Would that also provide you with other information? You mentioned that benzodiazepine wasn't considered addictive in the past. If we have the kind of tracking that clearly would be available in the system you have in B.C., we can figure out patterns and do something about a variety of drugs, and also look for interactions.

    Dr. Brian Taylor: First, I think it is important that you continually monitor drug use in people who are taking a group of drugs chronically. But I think also it's important to understand the action of the prescribed drug upon other medications they might be receiving. The PharmaNet program has, in fact, got a drug interaction program with it that will alert the pharmacist to possible interactions at the time of dispensing.

    The Chair: Dr. Kendel.

    Dr. Dennis Kendel: I just wanted to make the observation that while I think the program previously run by the federal government, where there were pharmacy inspections, had utility, if you had a comprehensive IT program, you could just push a button and download the data from every pharmacy, and you can do that analysis without somebody having to be on the road to truck around and do it.

    While it's not on the issue of inappropriate use or diversions to the street, I don't know if you've had a chance yet to hear anything from our colleagues in Quebec, but the Quebec College of Physicians and Surgeons instituted a very effective program in which there are data that show that benzodiazepines as used with the elderly increase hip fractures by creating instability. They instituted a monitoring program in which, if they detected physicians prescribing benzodiazepines to the elderly, they would interact with them, first in an educational mode, and if that was unsuccessful, in a somewhat more focused mode. If I remember correctly, in the first year of operation of that program, there were 175 fewer hip fractures in the elderly in Quebec than there had been previously. Quite apart from preventing the human suffering of hip fractures, the cost saving was enormous.

    I think, again, it emphasizes that if you have access to accurate data, you can do a number of fairly exciting things to begin to change things. Our provincial government has funded an academic detailing program where pharmacists conduct educational sessions with physicians to counter some of the pharmaceutical industry influence and to help them understand what evidence is best for prescribing practices. We've begun to see some really positive results from that. A program like that can make a difference as well.

    The Chair: Okay.

    We heard from somebody who was an addict, so it's anecdotal testimony--unfortunately, it does relate to the NIHB program--about physicians prescribing 90 Percocets, 90 Dilaudid, and 90 something else, with a double repeat, and their being able to walk into this walk-in clinic on a Saturday night--why you would need that to carry you over until Monday I'm not sure--and get not only the 270 pills they received, but also, in a very short timeframe, the double repeats, because no one really cared that it was a 30-day dosage. Because they were an NIHB client, the pharmacist was more than willing to hand over that kind of quantity. Is there a possibility that this could have occurred? It certainly caused us all a great deal of concern about what was going on. Obviously, this individual was sold at least half of those pills, and that's not an acceptable use of anybody's money, or of health care.

º  (1605)  

    Ms. Coleen Conway: I can't explain why the pharmacist would do that if it was ordered appropriately. We do suggest that prescribers use part-fills when they are prescribing large amounts of narcotics and controlled drugs, so that they limit the amount the patient can have within a timeframe. We also recommend to pharmacists in the province that if a physician has prescribed a large amount at one time, they turn that prescription into a part-fill, so that they are not dispensing large amounts. I can't speak for the pharmacists.

    The Chair: Even in that case--and this is open to all of you--if somebody is in a walk-in clinic on Saturday night, maybe they are in really serious pain, and we don't want narcophobia, which is a new word I learned today, but we want them to be able to get through until Monday and get back to their family physician. What's the process where a walk-in clinic on a Saturday night is prescribing anything more than enough drugs to last till Monday, so as to get an appropriate intervention back to the regular doctor? In each of your provinces is there something to say that's just not appropriate?

    Mr. Peter Hickey: Narcotic prescriptions are non-repeatable, so probably what you are seeing, as Coleen has said, is a physician saying, okay, I want you to have 1,000 tablets, to be dispensed 250 tablets a time, or something like that.

    The Chair: Maybe they got 30 of each right away.

    Mr. Peter Hickey: Possibly.

    Regularly in British Columbia, in our college newsletter we put tips and hints to physicians of things to be aware of or beware of, particularly with walk-in clinics. Beware of the travelling individual with the lower back pain requesting a medication by name. Not too many of the general public can walk in and say, I would like some Dilaudid. That should send a few red flags flying, I think. People arriving on Friday evenings are again a red flag, usually because they do that purposely. They know there are a lot of things closed, and therefore you can't check. For instance, if I am in British Columbia and say, I'm here from Saskatchewan--it's 5:30 or it's a walk-in clinic on Saturday--and my physician in Saskatchewan gives me Dilaudid regularly, but I happen to be out of it, that should raise doubts, because they know you can't check for that.

    So all those things the physician should be aware of, and we do that in our newsletter regularly--here's something for you to consider, this is a red flag, this is a red flag. We talk about lost and stolen prescriptions. Very few individuals have lost or stolen antibiotics. They do have lost and stolen narcotics. So that's again something you should be aware of. Also, certainly in our system, huge quantities are a flag. Most of us don't get 100 Dilaudid. Dilaudid 8 milligram have a street value in Vancouver of about $75 a tablet. That's a pretty good day's work.

    You have to be aware of that. These medications have a large street value. As Dennis mentioned, things like benzodiazepines, which people have a very nonchalant attitude about sometimes, do have a street value. There is a dependency issue there. That's why, certainly in our program, we have them in our system and we do watch them. It's important.

    Dr. Dennis Kendel: One of the reasons we need to move to state-of-the-art IT systems is that a doctor can only phone the College of Physicians and Surgeons to get access from their prescription database during weekday daytime hours. Addicts soon detect that, and so they selectively will seek drugs after hours, weekends. And of course, if you had a real-time system where the doctor himself or herself could get the information, you could overcome that.

    On the basis of the information you have provided, you always have to put it in the context of, there may be another side to the story, but it strikes me that it's inappropriate or inadequate professional judgment. We often point out to physicians that if we really just wanted to give people everything they ask for, we would put medications in dispensing machines like Coke and 7-Up. There has to be an exercise of some professional judgment; you don't always say to people, yes, I will give you the 90 whatever you are asking for. As Peter said, when patients say nothing else will work, the physician suggests alternatives, and they say, I've tried everything, only this particular drug will work. That should be a huge flag.

    Occasionally, there are physicians, as I mentioned, in the category who directly exploit the system. We had a physician in Saskatchewan who would make unsolicited house calls to apartment buildings, knock on the door, and ask if anybody needed any drugs. That person is no longer a practising physician anywhere in the western industrialized world, as his licence was taken away. For a while that sort of activity went on, until the bells rang and we took disciplinary action. There will be some sociopaths who make it into medicine and need to be taken out of medicine. That's still an important function for colleges. It's not a pleasant function, but it's an important public protection function.

º  (1610)  

    The Chair: Did that physician have a drug dependency? One of the things someone told us in the Nova Scotia example was that the physician had a drug dependency and there was some concern, as she recounted it, that he was in the detox centre. I said, my god, he was in there prescribing in the detox centre? She said, no, he was in the next bed. There was clearly something else going on, but it was shocking that the pharmacy didn't have information that the person knew what was going on was wrong. They, thankfully, were in a rehab centre. Hopefully, they are dealing with their addiction, but there are obviously, as you say, sociopaths in the system and breakdowns.

    How do we, as a society, work to increase awareness? It sounds as if you are doing a very good job in Saskatchewan and in B.C. Are there other things we need to include in a comprehensive national drug strategy that you see from your perspectives as colleges and provincial health people?

    Mr. Peter Hickey: I would like to make one more pitch, as I think it's extremely important. We've spent a lot of time on the methadone program, and I would urge this committee again to look at the buphenorphine situation. I think it's extremely important that buphenorphine be required to have a special authorization. It can cause a lot of problems. I think it would be a shame for the federal government not to take responsibility here. I don't know whether it's a resource issue or what the problem is, but I think it's extremely important. Physicians just can't start prescribing this drug. They need the training we give them and is required for this very special area of medicine. I leave it at that.

    Dr. Brian Taylor: I'd like to say again that the issue of Internet prescribing needs to be addressed. We need some Canada-wide legislation, I think, to prevent abuse of prescribing privileges in that regard.

    The Chair: Dr. Kendel

    Dr. Dennis Kendel: As you know, the federal government has its Infoway initiative, which links with many initiatives in provinces to build IT systems to support health care. I don't know when it'll come to be reality, but in some small centres in North America it is reality, where you have imbedded in such systems existing clinical care pathways and guidelines. Quite honestly, we think prescribing could be improved if we had reminders to physicians imbedded in those systems that when you're considering a certain condition, this would be the optimum way to do it. That might reduce some of the huge small area variation that we see across the country.

    The only other thing I would say is that in the push for primary care reform across the country, we anticipate that there will be more of a team approach to the practice of primary care. I do think that bringing pharmacists more deliberately into the team, if you like, in such a way that they don't just get a scrip without any information about the patient's condition will probably help to improve prescribing practices. I think that's a hopeful development as well.

    The Chair: As part of that, I'd like to see more people asking their pharmacist for guidance and having a discussion with them, especially when it comes to the OTCs, because often people don't seem to understand that those drugs have implications and could have interactions with the prescribed drugs. If they'd just ask the pharmacist, they'd get the information they need.

º  (1615)  

    Dr. Dennis Kendel: Sometimes it's hard to get physicians to acknowledge that there are professionals who in some areas know more than they do. Pharmacists devote their entire professional careers to understanding the appropriate use of pharmaceuticals, and it would make a whole lot more sense to make them integral members of the team.

    The Chair: Ms. Conway.

    Ms. Coleen Conway: I don't know how the federal government can assist us with IT solutions, but I think a lot of the problems would be solved if professionals had access to the patients' profiles and other databases to make sound decisions. Thus far in Nova Scotia we don't have that kind of access. Although we know Dilaudid is prescribed in abundance, we don't have access to other databases to tell us why it's a problem, and I think we need access to those. I think we need IT solutions for that.

    The Chair: Thank you.

    Mr. Lee.

    Mr. Derek Lee: I have a follow-up to Ms. Conway, and it relates to the benzodiazepine chart. I don't know whether the record of our hearings here today shows the chart, but it shows benzodiazepine tablet use in New Brunswick way up at the top, double what is used in Ontario and way above the national average. So that raises questions. We can only speculate why. Nova Scotia, by the way, for most of the last few years was a close second. I'm going to ask, do the procedures you use, manage, and work with tracking this stuff show the prescription of benzodiazepine to be way up on top of the charts? Had this ever come to your attention or that of the institutions you work with as an issue, simply because of the potential for diversion? Of course, we all acknowledge that what we're looking at here is almost all the medical use of drugs. These are drugs that are prescribed by physicians, and the committee is looking at the use of non-medical use of drugs, so we're looking at the diversion piece of that.

    Ms. Coleen Conway: As I mentioned in the presentation, we don't monitor benzodiazepines, but it has been brought to our attention that it is a problem and that we need to address it. Currently, we don't have any IT solutions that would allow us to do that.

    Mr. Derek Lee: What kind of problem is it?

    Ms. Coleen Conway: We have a very outdated, archaic computer system.

    Mr. Derek Lee: No, you said that benzodiazepine is a problem. What kind of problem is it? Is it an overuse problem, a diversion problem, or what?

    Ms. Coleen Conway: I don't know. Again, I can't answer that question for the simple reasons that we don't monitor it and we don't have access to other databases so as to even understand the reasons. Again, we need IT solutions to be able to address some of these issues.

    Mr. Derek Lee: Thank you.

    The Chair: It was referred to as a problem perhaps because you clearly are prescribing over the national average.

    Ms. Coleen Conway: Obviously, from the charts that have been presented today, it is a problem.

    The Chair: Although it may not be a problem if that's an appropriate use of benzodiazepine.

    Ms. Coleen Conway: We don't know why. Maybe Nova Scotians have a higher anxiety rate than the rest of Canada because they are separated from the rest of the country.

    The Chair: No doubt we're separated from Nova Scotians.

    Ms. Coleen Conway: Because we don't have access to other databases, we really can't give you a knowledgeable answer.

    Dr. Dennis Kendel: It's pretty unlikely that the health care needs of people in one province are vastly different from others, if you take large enough population samples to eliminate sociological factors.

    The benzodiazepines are used for a very broad range of indications, but one of their more common misuses is as ongoing sleeping pills. The literature clearly suggests that people ought not to be using sleeping pills day in, day out. When you're facing some life crisis or whatever and you need sleep, assistance for a few nights is reasonable, but most often, when you see such a pattern as that and you do an analysis, a large amount of that prescribing is for nighttime sedation. Nighttime sedation on an ongoing basis is not a recommended medical practice, full stop. There is no medical literature to support that, and there are lots of dangers with it. If you can identify that, you have to try to change the pattern through educational intervention, and frankly, if education doesn't work, you have to become more directive.

º  (1620)  

    Mr. Derek Lee: Do I take it, then, that it was the information system in British Columbia that identified this benzodiazepine issue?

    Dr. Brian Taylor: No, I obtained this data from IMS Canada. It, of course, has obtained the data from the various pharmacies in each province.

    What you have to do when you look at that graph is realize that it is just an indicator that there may be a problem. To look at the problem demands a lot more work. For example, if you found that 70% of the people in British Columbia on benzodiazepines are over the age of 60, that would be a big social problem. You have to consider it in far more depth.

    The thing I found astounding about that chart was that it is a straight line for the whole of Canada and for each province. There hasn't been any variation in use, whereas in our province it has been suggested that doctors are prescribing benzodiazepines irresponsibly, in an escalating form, and that doesn't seem to be borne out by the chart.

    Mr. Derek Lee: Thank you for that.

    The Chair: I guess the benefit, if we had this on-line system, is that we would be able to track where those 60-year-olds were. If they're all in institutions and people are sedating the people in institutions every night, we'd know we had an even bigger problem. If you had the tracking, you could figure out what was going on.

    Dr. Brian Taylor: That is a study that would be beyond the scope of the College of Physicians and Surgeons. It would be a really major task.

    The Chair: Dr. Kendel--who wanted to point out that the Saskatchewan people are the happiest people on the chart.

    Dr. Dennis Kendel: We're just very happy people. With grasshoppers and drought and everything, we're happy.

    I must say I'm surprised--and maybe it happened before I came to this meeting--that the word Ritalin hasn't come up anywhere during this dialogue. Ritalin is among the drugs we monitor, and as you may well know, there is still much controversy as to whether the current pattern or trend for prescribing Ritalin for attention deficit disorder is appropriate or not or it's been over utilized. Frankly, one of the most tragic scenarios is that often children are brought in and they do, in fact, have the disorder and need the medication, and it is prescribed for them, but the parents sell it on the street, so the kids never get the drugs. The children are used as pawns to get hold of Ritalin. That happens with very disturbing frequency. It's a very difficult societal problem, because children are not getting benefit of medication that might help them, and indeed, they are being used as pawns to actually divert drugs.

    The Chair: Does anyone else have any other questions?

    Mr. Kevin Sorenson (Crowfoot, Canadian Alliance): In a case like that, do you report them to authorities?

    Dr. Dennis Kendel: There is a very interesting legal question as to whether we can actually, of our own volition, turn information over to the RCMP or to any police agency. Most lawyers would tell you that we can't do that. Our privacy legislation would preclude that. If they develop awareness of the problem and they use a proper warrant, we make information accessible to them. The police agencies generally cannot get information directly about these things unless they are investigating an incident.

    Mr. Kevin Sorenson: Even for individuals you highly suspect of trying to rip off the system? Do you report them to the RCMP, or is that the same type of thing? Do you feel it is doctor-patient confidentiality?

    Dr. Dennis Kendel: What we say to our physician members is that they need not fear discipline from us if they believe that as responsible citizens, when they have an enquiry from the police about the misuse of drugs, they should turn information over to the police. We will not discipline them for that, but they are always at risk of civil litigation and other actions by citizens if they feel their privacy rights have been breached. It is a very sensitive area.

    Mr. Kevin Sorenson: So do you think the deck is stacked against you?

    Ms. Coleen Conway: Absolutely. In our province last year we had a case where a person had seen 42 physicians within a very short period of time. We knew it was a clear case of abuse and diversion. When we asked legal counsel if we could just go ahead and report that to the police, we were given advice that we could not, because of confidentiality issues. I don't know if that is anything the federal government can assist us with, but I know at least Nova Scotia requires legislation so that we can report to law enforcement directly when we see an abuse situation.

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    The Chair: As colleges of physicians and surgeons, you have talked about what you are doing on the prescription drug side. One of the things we noticed in B.C. particularly and across the country generally was that there was a lack of rehabilitation options. I'm not sure if you are the right people to talk about that. In Saskatchewan, for instance, we were impressed that Saskatoon had 12 youth facility beds--not that this is the only place to get rehab. Lower B.C. has six youth beds. The Saskatchewan people thought they were hard done by, and when we told them the scope of the problem in B.C., they felt a little better, but it still is not enough when you are dealing with kids who have drug addictions. Of course, the adult population is also apparently underserved. Is that an issue that either of you is able to talk about or encourage us on?

    Mr. Peter Hickey: That is certainly an issue we are well aware of. It is not in our mandate. We speak regularly to the provincial government regarding this. We do that through our advisory committee on opiate dependency. We are very aware. It becomes a huge money issue. Certainly, in British Columbia we need residential treatment centres very badly. We have been speaking to that for a number of years now. When the extra funds will come is anyone's guess. In British Columbia the cost of methadone treatment alone is astronomical. What we are trying to get across to the provincial government is that for every dollar spent in this area there is a $7 to $11 saving to health care.

    The Chair: And the justice system

    Mr. Peter Hickey: Still, you're talking to politicians, and when you start talking about money, particularly when they are trying to get the fiscal house in order or whatever, money is hard to come by. We are well aware of that, and it would be number one on the wish list as far as our program goes.

    Dr. Dennis Kendel: The first comment I would offer there is that we have a very significant aboriginal population. With transfer increasingly to bands and tribal councils for management of their own health care services, I would say, on average, aboriginal people are doing a very good job of making rehabilitation a very high priority, both on reserve and in the urban communities.

    The second thing I think is positive is that although many people see downsides to the move toward regionalized governance in which these regional health boards have a responsibility for a very broad range of health services, we are beginning to see a breaking down of the silos between health, social services, justice, etc. and a better understanding that there are many determinants of health. As Peter has pointed out previously, if you spent money on the health side and achieved cost savings on the justice side, you didn't get any credit for that. Now I think people are seeing health more globally and recognizing that if you make investments in one side and derive benefits on the other side, it justifies expenditure, and you ought to think about the entire spectrum of human services, not just health as a silo. So I think there are some positive developments there.

    The Chair: Dr. Taylor.

    Dr. Brian Taylor: I was just going to add that as I am sure the committee already understands, detox and methadone programs are just arrows in the quiver. Somebody with the disease of addiction needs a whole spectrum of care, including counselling. Currently, that is not a funded service in British Columbia. To expect somebody who is stealing for their drugs of addiction to fund their own counselling services is not realistic. If society really wants to address this problem, I think it's going to take a lot more funding than we currently have.

    The Chair: Thank you.

    Madame Allard.

[Translation]

    Ms. Carole-Marie Allard (Laval East, Lib.): I think that it's Dr. Kendel who said that he would like to have...I thought I heard you say that you would like to see a better integration of pharmacists into the current system. Did I understand you correctly? You spoke about better integration of pharmacists in perhaps supervising prescriptions given to people.

º  (1630)  

[English]

    Dr. Dennis Kendel: Yes, I did say that. It's incorrect when you look at the practice of pharmacy. There are really two very different worlds, hospital pharmacy and community-based pharmacy. In the hospital setting the pharmacist is a more integral member of the team. So if you look at an infectious disease service, for instance, once the nature of the infection is identified, the pharmacist is often the principal person who suggests what the most appropriate regime of antibiotic therapy would be. So it's a real team approach. On the community side, in the traditional model, the patient goes to see the doctor, shares certain information with the doctor, the doctor writes out a scrip. The patient goes to the pharmacy, hands in the scrip. The same medication might be appropriately used for five different reasons. The pharmacist has no understanding, unless the patient elects to share the information, of why that medication is being used, and therefore is often disadvantaged in giving optimal advice about its use.

    So I think, if you could essentially emulate the hospital system.... And quite frankly, the CLSCs in Quebec, I think, are a model, to some extent, in which there is better integration of the services of other health professionals. That probably will become more the norm.

[Translation]

    Ms. Carole-Marie Allard: There are three medical associations. Does each province have a medical association? When you express this kind of an opinion, do you include the Collège des médecins du Québec? Are you each speaking on behalf of your respective associations, or do you have a structure that could be national in scope, where you can share you ideas? There are three provinces represented here today; four in fact, with Madame.

[English]

    Dr. Dennis Kendel: Yes, there is a federation of medical licensing authorities in Canada, given the nature of the Constitution. Health is a provincial jurisdiction. The regulation of all professions, including physicians, is strictly provincial. There is a national network through which we do share information.

    I think it is important to recognize that colleges of physicians and surgeons across the country vary substantially in the rigour of their programs to deal with this. I think the college in Quebec is actually an excellent college; it is very well resourced and has a very broad mandate. Because colleges depend mostly on the fees they charge doctors for licensure, if you go to the province of Prince Edward Island, where there are 170 doctors, it's pretty hard to run a very effective college. Increasingly, we need to think about strategies on a national level, even though we continue to derive our legislative authority provincially. We need to look at strategies of doing things more uniformly across the country.

    The Chair: Thank you. That was very helpful.

    Thank you to all of you for coming across those mountains all the way to the east, where it's a beautiful sunny day. We have had good weather a lot this summer. For the east, thank you very much for coming into the centre and for putting together your presentations and sharing your ideas with us. It is going to make a huge difference in how we develop our report. If anything pops across your desk that you think we might benefit from in the next couple of weeks, we would certainly love to receive that. Thank you, on behalf of all Canadians, for the work you do in your communities and your provinces every day. It makes a big difference, and we appreciate that.

    Colleagues, we will suspend for a few minutes.

    [Editor's Note: Proceedings continue in camera]