[Recorded by Electronic Apparatus]
Tuesday, March 4, 1997
.0906 
[English]
The Chairman: Order, please.
Good morning, everyone. We have a vote that should take place around 10:30 a.m.
Secondly, once we have heard from the witnesses, if there is enough time before the vote, I propose that we have a short meeting to deal with two or three items that are mainly housekeeping items, such as scheduling in terms of Grant's motion about the visit of the minister to the committee, and two or three issues like that. If there isn't enough time, we'll have to provide for it next week. Keep those things in mind, if you will.
Let's hear from the witnesses now.
We are pleased to welcome all three of you. Thanks for coming. This is going to be kind of a round-table approach in which we have witnesses from each of three different agencies or organizations who I hope will give us the benefit of their wisdom - briefly at first - and then we can have an exchange among them and between them and the committee.
Whoever would like to start, please feel free to do so, and introduce yourselves, and so on and so forth.
Dr. Usoa Busto (Department of Biobehavioural Research, Addiction Research Foundation): Good morning. I'm Usoa Busto from the Addiction Research Foundation. I've been working for the last twenty years on prescription drug use, abuse, and dependence. I was told that the committee's interest is the abuse and harmful use of and dependence on prescription drugs. I was told that I should do a short presentation, after which there will be questions. So that's what I will do.
As you all know, prescription medications are those that are available with a doctor's prescription. You cannot obtain them by going into a pharmacy and getting them. Most of these medications are effective in treating diseases or in treating symptoms or signs of disease. I think this is very important in the case of prescription medications: if these medications are used appropriately, they are invaluable instruments for preventing and treating disease. These drugs or medications are not like illegal drugs, which don't have any potential benefit when used. These are beneficial medications, if you use them appropriately.
Prescription medications are rarely abused. For example, antibiotics are used every day all over the world and they are never abused. Diuretics, cardiovascular drugs, and drugs for hypertension are never abused, mainly because for a medication or a drug to be abused it has to produce certain pleasant effects. Most prescribed medications do not produce these pleasant effects, these effects that we call reinforcing effects, which lead to abuse or dependence.
Some classes of prescribed medications do have the potential to be abused and do produce these pleasant effects I am talking about. These medications include opiate analgesics such as codeine, morphine, hydrocodone - Percodan, Percoset and Tylenol 3, which are medications - and some tranquillizers and sedatives, including barbiturates, which you probably know about, such as Secobarbital or Amobarbital. The barbiturates are rarely used these days, so this is not a complication.
.0910
[English]
Another class of drug that is frequently used as a tranquillizer or sedative is the benzodiazepines. You have probably heard of Valium, Ativan, Halcion, and others in that class. These are frequently prescribed.
You may also have amphetamines in this class. They are very rarely prescribed, only for a very specific indication, but the potential for abuse is there.
Even if we take into account only these classes of drugs that have the potential to produce abuse or dependence, the majority of individuals who use them use them appropriately or their physicians prescribe them appropriately. And we have all taken Tylenol 3 after dental surgery for three days and nothing has happened: you've never abused it and it took away the pain. Morphine is the same. It's used every single day in all hospitals after major operations - for two or three days until the pain subsides - and is never abused after that. Many people use hypnotics or tranquillizers for transient insomnia or anxiety and there is never a problem afterwards.
The point is that the majority of people who use even the drugs that have the potential to be abused use them appropriately.
Some individuals, however, do abuse them. These are typically subjects who also abuse other drugs. With these individuals it is very difficult to decide whether the harmful effects they are getting come from abusing these prescribed medications or from all of the other medications or drugs they are abusing. These are people who use cocaine, alcohol, and amphetamines, and on top of that they abuse barbiturates and opiates and whatever. It is very difficult to decide whether their problems are caused by the prescription medications or by the other drugs.
That said, you have to look at the other side of the coin. These medications may produce - and I am referring to the ones I talked to you about, the opiates and benzodiazepines, which are the major ones - a physical dependency if they are taken for long periods of time, even if they are taken appropriately for periods of time, for example, for one year, six months or more.
Physical dependence means that if the person tries to stop the medication abruptly he has a withdrawal syndrome that may prompt him to keep taking the medication. People tend to keep taking it and cannot stop.
Some opiate analgesics, such as codeine, are used regularly for prolonged periods of time for patients who have pain. You have to be careful. We were discussing this with Dr. Carter. In some cases with these medications you have to balance the benefit you're getting with the risk of dependence.
Tranquillizers such as Valium can also be prescribed for prolonged periods of time and can be appropriately prescribed in some cases like panic disorder or generalized anxiety disorders. Tranquillizers can also produce dependence. Again, you have to balance the benefit of prescribing for a prolonged period with the risk of having this medication prescribed.
In this particular case of medications used in lower doses for long periods of time, we do know that dependency is more frequent than abuse and that women and the elderly receive the majority of these prescriptions. In many cases they do have difficulty stopping these medications, or there is a risk of toxicity, such as increasing the incidence of falls for the elderly, falls leading to hip fractures in some cases.
So the other side of the coin shows that medications are not that beneficial in some cases.
.0915
With respect to health policy, the most effective measure for reducing possible problems with these drugs and prescription medications comes through education. Regulatory measures are very effective in reducing use of these medications: you put a regulatory control on one of the prescription medications and use will go down dramatically. But these regulations may then backfire. Why? It's because the patients who are being treated appropriately are not going to, or may not, receive this medication. They are, however, going to receive another medication that may be more dangerous.
So with respect to the health policy, I think our opinion is that one has to be very cautious in making regulatory measures before educational measures are in place. People and health professionals must understand why the regulatory measure is in place and not switch from one medication that is being used to another that may be more dangerous.
I think that's about all I have to say.
The Chairman: Thank you.
Who's next?
Dr. Robyn Tamblyn (Associate Professor, Department of Epidemiology and Biostatistics, Department of Medicine, McGill University): I think I'm next, because something magical has turned on my microphone.
I'm Robyn Tamblyn, an epidemiologist from McGill University. My work has been in prescription drugs for seniors.
You are probably aware that seniors will fill four out of ten of all drugs prescribed, so the issue is poignant for seniors. Seniors are also -
The Chairman: What was the stat you just gave?
Dr. Tamblyn: For every ten drugs prescribed, four will be prescribed to seniors.
Seniors, as you know, are 12% of the population. This is the main group; this is the fragile group. And guess what? People live longer, they have more chronic health problems, and they're going to get more drugs. I realize that what seems to be the pressing issue for most people is the fact that drug costs are spiralling at a rate that is uncontrollable. Until recently, Quebec spent three-quarters of a billion dollars a year on prescription drugs. Ontario spends $1 billion. The increases are in the neighbourhood of about 17% per year.
Everybody's concerned. Are you really getting a good bang for your buck? Is this working? I think that's what I want to talk to you about today. My answer is that I don't think it's working. As a solution to this problem, we should stop trying to blame people, because that in itself is not working. We can blame patients for demanding, physicians for prescribing, and pharmacists for dispensing, but it's not going to solve the problem.
What I would like to take you through are essentially three messages. One is that the information we know, that we spend billions of dollars on in terms of research and in trying to find out, is in fact not getting to the grass roots. It's not getting to the people who need to have that information to make decisions.
The second issue is that there is too much to know. In this day and age, nobody at the front line can keep up to date. To imagine that they could, particularly in the area of drugs, is being unrealistic.
The third is that we can do something about it. In Canada in particular I think we can do something about it because we have a home-town advantage in being able to tackle this problem of getting information to the grass roots, where it is needed to make decisions.
I've given you some handouts here because I just want to illustrate this problem. The second picture here essentially says that there was one thing that we learned in the drug area of interest specified in the terms of reference - psychotropic drugs, long-acting benzodiazepines, the ones you'll probably know more familiarly as Valium or Diazepam. What was known about those drugs is that they were safer than barbiturates, which used to be prescribed in the sixties to treat people's anxiety problems and sleep problems. They were replaced by these long-acting benzodiazepines, which indeed were safer.
What became known, particularly in seniors, is that these drugs produced problems in cognition and in coordination. For seniors who basically cannot eliminate them as quickly, that in particular becomes a real issue. People fall when they get older, their bones are more brittle, and they're more likely to have fractures. That information was known in the seventies. There were a hundred epidemiological studies between the seventies and eighties that pointed to this in a systematic fashion. What's present in the nineties is that 12% of seniors are still getting this drug.
.0920
So what are the consequences? You don't know for many potentially inappropriate prescriptions, but you do know here. There are about 5,000 admissions for fractures in Quebec - and I'm going to talk about Quebec; we can talk about Canada in general, but my work has been done mostly in Quebec. Of those, about one-fifth of them, or about 1,000, are due to the fact that people are using long-acting benzodiazepines.
Let's look at the other side of the coin, because it's not simply people not knowing the information about the harm in drugs. The second piece is that they don't know about the good either. It's not getting there. So if you look to the next page, we can look at the issue of betablockers.
Betablockers were brought into the market in 1951 for use in the treatment of high blood pressure. By the sixties it had become known that these drugs were in fact effective in reducing the likelihood that you would have a second myocardial infarction - a heart attack. Between the seventies and nineties there were at least twenty clinical trials done on these drugs. Over 25,000 patients were randomized. The effect was dramatic. When you're on these drugs, you can reduce the risk of having a second MI by at least 20%, and among seniors that figure is 50%.
If you look at what we spent on learning this, it was $2 billion. We spent that much on learning about these drugs and their beneficial effects. If you look at the proportion of seniors who have had an MI and who are prescribed these drugs, it's 21%. What does that mean? It means that - and again I'm going to use Quebec stats - 14,000 MIs occur every year. Of those, essentially we're actually preventing about one-quarter of them. We could prevent another two-thirds, but the information about betablockers is not getting to the grass roots. The same is true for drugs that produce harm. The question is why.
We can start blaming, and we've done that very well. I think the issue here, however, is that Canadian training for physicians and pharmacists is probably among the best in the world. What is known is that once people are trained and out in a practice, they do very well. But knowledge changes over time, and it changes dramatically. The once-a-year or twice-a-year CME things are not going to work to continue medical education. They're a drop in the bucket. In terms of knowledge, drugs are probably the things that are changing the fastest.
If you look at the next thing, 1,000 drugs were available at the turn of the century. We now have at least 24,000 drugs that have been approved for marketing in Canada. This has been a dramatic increase. Five drugs were approved by the Drug Protection Branch in 1940. In the last three years there have been 1,500 approvals per year. Can you imagine trying to keep up to date on this? Do you know what that translates into? It translates into 33,000 different drug interactions that have been documented, 6,500 drug disease contra-indications that someone would need to know about, and over 3,000 drug allergy contra-indications. This is too much for anyone to know, yet this is only a piece of the pie in terms of providing the best you can in primary care. We simply have to tackle the problem.
For the elderly, it's further complicated by the fact that we have had chronic problems in communication in the health care system. When you're dealing with super-specialized care, and when you're dealing with someone who has many health problems and is getting the best he or she can get, it fragments the whole process.
If you look at the next page, it's evident that many people have multiple prescribing physicians. This is not uncommon for people who are receiving health care from many different providers. They're seeing rheumatologists for their arthritis, they're seeing cardiologists for their heart problems, and they're seeing primary care physicians to coordinate their preventive care. As the number of different providers of care increases, however, not only does the likelihood that they're going to have a potentially inappropriate prescription increase, but the share that's being produced essentially by multiple prescribing physicians - one person is prescribing one drug and someone else is prescribing another drug - is also increasing. We assume they don't know what the others are doing.
.0925
Our challenge has been to provide a solution to this. It really has not been productive to continue trying to blame people, because we don't think it's possible for anybody to keep up to date.
There's no point in dealing with the fringes of people who are rushing around doctor-shopping. This is not the bulk of what's going on with seniors. The bulk is that they are having their health care managed by a number of different people. This is probably good for them.
So how can we solve the problem of chronic communication? How can we solve the problem of getting important information that we spend a big bundle on in terms of health research in Canada to the grass-roots level, where it will make a difference?
Our solution has been to say we could harness the available technology to do this much better. In doing so, I think we could continue to take some leadership role in Canada in trying to actually bring health care, the paper-bound, hopelessly-difficult-to-communicate health care system, into the next century.
We're trying this in a study in Montreal. In essence, we're doing two pieces. We need one piece to solve the communication problem. The piece actually exists. We have a universal health care system. The drugs dispensed yesterday are known by the government in Quebec today. We can let physicians at the front line know that information. Why not? It will be so much more helpful in terms of trying to make their decisions.
So in an unusual initiative started in this province, the province agreed to download information to physicians' offices from their big mainframe computers in Quebec City so that physicians would know, at the moment they're seeing a patient, what drugs, of the ones I've prescribed, were dispensed - meaning, are people actually filling the prescriptions they need to control their high blood pressure so they won't have a stroke and spend 99,000 days in hospital - and what other drugs are being prescribed.
If the person went to the emergency room and got something for their fever, their pneumonia, the physician needs to know that. They need to know what else is going on. This information, courtesy of software designed by a private company started in Montreal, essentially confronts the physician with two pieces of information they need: what drugs were dispensed that were prescribed by somebody else and what drugs were dispensed that were prescribed by me. So we're trying to take advantage of information we have that's unique in the Canadian health care system to make better decisions at the front line.
The second piece is to say, okay, let's bring into practise information physicians need to have by using automated surveillance. We put in the physician's computer the diseases people have. It now becomes an electronic chart. The system itself actually runs a surveillance for problems in their prescriptions.
It alerts the physician. It tells them, for example, that the person is on two benzodiazepines, a duplication that increases the risk of overdose toxicity. We can tell them that this would increase the risk of falls, confusion, motor vehicle accidents, and fractures. If you have to use drug therapy, at least switch to a short-acting product, but try non-pharmacological approaches.
We tell them that if you prescribe an NSAID, a nonsteroidal anti-inflammatory drug, to someone with peptic ulcer disease, it increases their risk of having a GI bleed. We tell them it is inadvisable to do so unless it's absolutely necessary, and if you have to, use a gastro-protective agent.
There are over 60 alerts in this program, alerts that were identified by an expert panel of people across Canada as being clinically important and relevant to prevent prescribing problems in the elderly, to prevent avoidable morbidity and mortality.
This is the beginning, really. There are so many more things that can be done this way. What we're trying to do is harness the information we've learned from research, bring it to the grass roots and let them use it to make the best decisions possible for Canadian seniors, not just with prescription drugs but ultimately with other medical treatments.
Thanks very much.
The Chairman: Thank you.
Dr. Carter.
.0930
Dr. Anne Carter (Director, Health Programs, Canadian Medical Association): Mr. Chair, members of the committee, the Canadian Medical Association is pleased to be here today to present its perspective to the round table on prescription drugs.
The Canadian Medical Association is a voluntary professional organization representing the majority of physicians in Canada. The association's mission is to provide leadership for physicians and to promote the highest standards of health and health care for Canadians.
As the voice of Canadian medicine, our association has taken a great interest in drug and prescribing issues. Prescribing is central to medical therapeutics. As such, it sets the medical profession apart from other health professions. The CMA is vitally interested in fostering the quality of medical care. Quality prescribing is a cornerstone of this. Thus, we have initiated a number of projects on this theme in recent years.
We have worked in partnership with pharmacists, represented by the Canadian Pharmaceutical Association, to develop collaborative approaches to enhancing drug therapy for Canadians. The resulting policy statement, Approaches to Enhancing the Quality of Drug Therapy, was published in 1996 and is being made available to this committee. It has engendered considerable interest in the health care community. Multiple copies have been requested for use in, for example, medical school curricula and continuing medical education courses.
As well, in partnership with CPHA we have developed two clinical practise guidelines to enhance prescribing. One deals with the use of benzodiazepines for anxiety - in fact, Usoa was on the committee that did that - and the other is the use of barbiturates containing analgesics for control of chronic pain.
These guidelines will be submitted for peer review to the Canadian Medical Association Journal, and are not yet available for distribution.
In partnership with Health Canada and the Canadian Medical Society on Alcohol and Other Drugs, now called the Canadian Society of Addiction Medicine, the CMA held a workshop on physician prescribing practises in the fall of 1995, the goal of which was to identify ways of enhancing prescribing practices. The background papers commissioned for the workshop and the proceedings and a summary of the recommendations are being made available to the committee.
In summary, the major recommendation was the development of a national drug information system based on provincial and territorial drug information systems.
I am delighted to see Dr. Tamblyn. Her project is actually exactly what these recommendations were based on.
The CMA was very active in attempting to improve the Controlled Drugs and Substances Act from the time it was first introduced in the House of Commons in 1992 as Bill C-85 until it was passed into law in 1996 as Bill C-8. While the CMA supported much of the intent of the act, it was felt that some sections would lead to reduced quality of care, and so spoke out against them. Copies of the CMA brief are also available.
The CMA has developed several other relevant policies, which are also available. As a member of the Canadian Coalition on Medication Use in Seniors, the CMA developed policy guides to guide physicians when prescribing for the elderly. The CMA has also developed policy on drug product substitution and drug labelling.
All of these policies are designed to enhance the quality of drug therapy for patients. In addition, the CMA has a policy on the role of physicians in prevention and health promotion. Clearly, the prevention of substance abuse is within the scope of this policy.
Finally, the CMA is currently developing a project that will assist physicians to manage substance abuse issues in their practice. Done in conjunction with the Canadian Society of Addiction Medicine, the Canadian Psychiatric Association, and the College of Family Physicians of Canada, it is one of the eight ongoing priority projects at CMA.
The CMA is attending this round table because it has significant experience and a keen interest in the field of quality prescribing. We hope our knowledge and experience can assist the Standing Committee on Health as it examines substance abuse policy.
Thank you, Mr. Chair. I would be pleased to answer any questions the members may have.
.0935
The Chairman: Thank you, all three of you.
We have some people who would like to ask you questions, but before we go to that, if there's something among yourselves you want to sort out, attack each other's position, whatever, you may take a few minutes. Does anybody want to respond to anything that either of the others has said?
Dr. Tamblyn: We're in harmony down here.
The Chairman: I was afraid of that. Don't say you weren't given the opportunity.
I will now recognize Pierre, then Grant, then John.
[Translation]
Mr. de Savoye (Portneuf): Your three presentations were most interesting. First, Dr. Busto, you outlined the problem for us: most people do not abuse prescription drugs, but some do, because they find it somewhat pleasant.
Next, Dr. Carter, you said that in order to react properly, information is required, and that consequently, it would be appropriate to have a national drug information system.
Dr. Tamblyn added that while it is all very well to have information, we have to be able to make it available and interpret it correctly. So much information is available that no ordinary mortal could be familiar with all of it and understand its practical implications.
In fact, Dr. Tamblyn, you spoke about an expert computer system that would use information that has already been registered, in Quebec, but probably in the rest of Canada as well, to enable doctors and pharmacists to make the right decisions and to avoid the dependency problems that may occur when drugs are combined for long periods of time.
So, I certainly understand, Dr. Busto, that drug dependence problems are not necessary caused by peoples' willful actions, but rather result from combinations of prescriptions that they should perhaps not have been given. They are victims, rather than the cause of their own misfortune. Am I right? Is that in fact what you are saying?
[English]
Dr. Busto: To most of this I would say yes, you are correct. It is not necessarily the patient who is responsible for these long-term prescriptions, but in some cases they are. They push physicians very much because these drugs work. If you want to go to sleep, you get one of these drugs and you go to sleep, so the patients push a bit. So to the people who are receiving the medication, it is also important. But in the majority of cases these prescriptions go to people who have problems and they make them feel better.
At the beginning it's probably appropriately prescribed, and then it begins a circle in which the physician prescribes the medication for a certain period of time to treat an appropriate concern at the beginning - anxiety, insomnia, pain - but then they don't keep looking at whether it is needed any more and the medication is continued for long periods of time.
For example, the elderly are anxious patients because they have other sorts of problems; they can't sleep and so on. It's inappropriate prescribing in the majority of cases, but it's a bit more complex than that. There are some other forces pushing for these prescriptions, or people will push for obtaining a prescription to the doctors, to the nurses, to the pharmacies, and so on. In general, you are correct, but there are more forces than that working.
.0940
[Translation]
Mr. de Savoye: You spoke about the need for education and information. What is an effective way of conveying this information to the public or to patients? Are doctors in the best position to do this? Or should it be pharmacists? Should the government be playing a role in this regard? How do you see this?
[English]
Dr. Busto: Do you mean the patients? Who gives the information to the patients? Usually, it is the pharmacist who is supposed to give the information on the drug. The physician gives general information, but the bulk of information about the possible problems associated with any medication usually rests in the pharmacist's counselling.
So that other person also has to be informed about what's going on.
[Translation]
Mr. de Savoye: Yes, Dr. Carter.
[English]
Dr. Carter: I certainly agree that the pharmacist has a responsibility to give the information. However, by law, when a physician prescribes for a patient, the physician is required to make sure the patient is fully informed about the risks and the benefits of the therapy prescribed, and consents, actually, to that therapy with fully informed knowledge.
So the legal requirement is with the physician as far as obtaining consent. There is also, in some provinces, a legal requirement for the pharmacist to make sure the patient is informed.
Dr. Tamblyn: My answer is that it's too important to get it wrong. Individuals should have direct access to that information. It shouldn't be that you have to go to the health care system to see a professional to do it. They should have access. Physicians should have access. Pharmacists should have access and be providing that information. It is too important to get it wrong, so I would use the triple-hit system.
Mr. de Savoye: Are you suggesting this should be put on the Internet?
Dr. Tamblyn: If I thought I could get a senior to get on the Internet, yes. I would use all pathways to get there.
[Translation]
Mr. de Savoye: Dr. Tamblyn, you presented the MOXXI system as a solution to the problem. I presume the system would be available to doctors and pharmacists. However, if such a system is to be used and used correctly, it must be easy to use and not meet with any resistance from pharmacists and doctors. How do you think these professionals would react to a system of this type?
[English]
Dr. Tamblyn: You're absolutely right. It has to be easy to use it. It can't be any more difficult to provide care through this route than it is today.
The fascinating thing about this is that, number one, pharmacists are currently using systems, by and large, in actual fact to do what I call drug interaction surveillance. That's the 33,000. But that's not going to be the most important piece, because the most important piece is drugs given to people that are contra-indicated by the diseases they have. For that we had to go to the physician piece.
Five years ago I would have said this is impossible, there's just no way on earth you can get a physician in the health care system to use this. I don't say that any more because of the software that has been developed, the speed of the computers, and, the most enticing carrot of all, to have information that takes you forever to get in any other way. To question a patient as to what drug he is taking, it is not good enough for someone to hear it's the green pill, the white pill, the purple pill. There are 300 white pills.
So it's the carrot in the system. We can make some things much easier for them to do, and they have to learn how to use a computer. It's doable. We are doing it.
[Translation]
Mr. de Savoye: Are you telling the committee, Dr. Tamblyn, that you recommend that the government support the implementation of such a system as part of its national strategy on drug control?
[English]
Dr. Tamblyn: Yes, I am. And I think it will support many other things, not just drugs.
[Translation]
Mr. de Savoye: Would you care to add something Dr. Carter or Dr. Busto? Dr. Carter.
.0945
[English]
Dr. Carter: First of all, I would like to say yes as well, to answer your question. As I said, we had this workshop in the fall of 1995. We called experts together from all across this country to discuss this very issue and yes, that's exactly what they talked about. They talked about building a drug information system that would start provincially and build to a national level. It's exactly what Dr. Tamblyn has described to you: bring all that information back and bring it to the physician-patient decision-making point. Even things such as the cost of the drug, the coverage the patient has for their drug - even these pieces of information currently are often not available and do influence the decision of both the patient and the physician.
One other item I would like to have added when you asked Dr. Busto about whether the patient is the victim - we got into a discussion about whether it was the patient or the physician who was pushing the use of these medications - the one thing I think is important to realize is that alternatives to the use of medication are not widely available to patients or physicians. We are aware that non-pharmacologic approaches to many of these problems are actually the method of choice, but particularly with the cutbacks in the current health care system these alternatives are not widely available. If you can't sleep or you're being troubled terribly by anxiety and it's ruining the quality of your life, if you have no other alternative, you will choose to go on medication rather than choose the alternative that is available to you, which is nothing.
Really, our health care system should make the non-pharmacological alternative available. It's a matter of short-term pain for long-term gain. Some of these alternatives are seen as expensive in the short run, but when you look at the long-term damage that's done by these medications, the health care system would be much further ahead to invest in these alternatives.
Mr. de Savoye: Ms Busto.
Dr. Busto: About putting the information on the Internet, the answer to that is also yes, I think it would be very helpful. Again, I would have some concerns about what sort of information is in there, but the fact that the information would be available quickly for the physicians, for the nurses, for the pharmacies that have some source of information already in place would definitely help - again, including costs, because often you ask a physician how much this medication costs and they have no clue. It's the best medication there, or they think it's the best, and it's new, so they prescribe it; and it's a hundred times more expensive than the one that does equally well but is cheap.
[Translation]
Mr. de Savoye: That was very interesting and very long as well. Thank you.
[English]
The Chairman: Not really, but I want you to know you took a little extra time.
Grant.
Mr. Hill (Macleod): Thank you for your presentations.
If we in Canada adopted MOXXI today, how many physicians' offices have the capability to receive the information?
Dr. Tamblyn: Meaning how many physicians are computerized?
Mr. Hill: Yes; what percentage today?
Dr. Tamblyn: Most computers in office practices used for billing are used by the receptionist. They are not used as the mainstream in health care. That doesn't mean they couldn't be. We all know the health care system is gradually, like a huge elephant, moving to be computerized: the hospitals, the labs.... The private offices are probably last on the list. We're making a big shift from doing it on paper to doing it electronically.
To make the shift is going to require careful planning and cunning. I think what's in place in Canada is quite a number of software industries that are trying to tackle this very issue. It's also being tackled in the U.S. Our home-town advantage is that we have information they want and we can provide and it will make their lives easier.
.0950
Mr. Hill: Do you know what percentage today would have it computerized?
Dr. Tamblyn: You would probably know, Anne.
Dr. Carter: We have some survey results. Close to 90% or more of physicians' offices have a computer in the office. But the use of that computer for the actual health care of the patient is much less than that.
Mr. Hill: Is it 5%?
Dr. Carter: Maybe 10%. It's the larger clinics that are moving to these computerized systems, so you get a larger number. But the actual locations are small in number.
Two things are slowing it down. Health care itself is the least computerized of all sectors of our economy. The two things that have probably held that back the most have been the lack of a good computerized patient record system and the lack of voice recognition technology. Both of those have come along quite well recently. There have been a lot of breakthroughs, almost, in those areas. Once those two hurdles are crossed I think you will see health care moving rapidly to computerization in the next short while.
Mr. Hill: One of the big problems with an electronic chart is confidentiality, and you talked about all the diagnoses being available to all the treating physicians.
Dr. Tamblyn: No, I didn't. I totally agree with you. In fact, I was so frightened by this.... We have the Bioéthique centre at the University of Montreal, with Dr. David Roy. Bartha Knoppers is the lawyer looking at the ethical legal issues. Ethical legal issues of a major nature arise in our project maybe once a month. There are periodic crises.
The territory is largely unmapped. The issues of guidelines for protecting confidentiality have not been made explicit. The technology is present to do it and we've crossed extraordinary hurdles to make this happen; just to see whether this works in Quebec.
What I'm trying to say is yes, it's an absolutely important issue. Yes, people's confidentiality can be protected. There are some very difficult issues you're going to have to tackle, such as whether the physician has a right to know when a person is actually getting medications from three different people and doing it quite deliberately. There are going to be some hard questions to answer. But the ability to protect someone's confidentiality is present. We have to adjust the laws and we have to provide the ethical guidelines for the use of this technology, there's no doubt about it.
Mr. Hill: Do you see this technology replacing triplicate prescriptions?
Dr. Tamblyn: Yes.
Mr. Hill: This will replace the need for that completely?
Dr. Tamblyn: Yes.
Mr. Hill: You talked specifically about natural methods of treating insomnia. Would you expand on that a bit?
Dr. Carter: I was talking about non-pharmacologic methods in general. For both insomnia and anxiety, for example, which are the two major reasons why benzodiazepines are prescribed, there are non-pharmacologic approaches: relaxation techniques, hypnosis. Something called cognitive behavioural therapy for anxiety, particularly in panic attacks, is recognized as being now probably the most effective approach to these problems.
Mr. Hill: Finally, you mentioned interactions between various preparations. What do you think of labels on alcoholic containers? I'm talking about interactions with tranquillizers and so on.
Dr. Busto: On alcohol containers? It's an interesting idea. I've never thought about it that way. We usually think about it the other way. Most containers for tranquillizers do have warnings about alcohol.
It would be interesting to see how much.... I'm not sure I have the epidemiology of this right at the top of my head. How many people who drink alcohol at the same time also use one of these drugs? To put it on all alcohol containers may be a bit much, because a lot of people would just take alcohol at lunch and would never take another medication, which would add to the alcohol problems.
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The Chairman: Next we will hear from John, Paul, and Herb, in that order.
Mr. Murphy (Annapolis Valley - Hants): Thank you, Mr. Chairman.
Thank you for your three presentations.
What I'm gathering from Dr. Tamblyn in terms of trying to get to the grass roots, to the people, is that a number of strategies need to be looked at.
I think Health Canada now has a program...I'm not sure if it's just a pilot project, but I happen to know that there are two projects going on in my riding where seniors are getting grass-roots education about medications.
I'm not sure if you're aware of that. Do you think the format, the process, is a good one? Does it get at your first recommendation? I ask the other witnesses to comment as well. Is it a good model as an adjunct to MOXXI and the others?
Dr. Tamblyn: Is your area in Ottawa?
Mr. Murphy: No, it's in Nova Scotia.
Dr. Tamblyn: Can you tell me what's being done?
Mr. Murphy: I'm sorry, but I don't have a lot of the information. I know that grants were given to health organizers in two parts of my riding so that they could work with seniors groups and clubs, through the general practitioners and the pharmacists, to try to get education about drugs and drug usage to the seniors in particular.
Dr. Tamblyn: It's true that Health Canada supported a number of community-based initiatives. This deals with some of the issues in seniors helping seniors, which I think is a very positive thing, but the thing that discourages them is that you only tackle one side of it. With respect to prescription drugs, it's the physicians, the pharmacists, and the patients, and if you only tackle one side of the receiving relationship, it doesn't work very well and seniors give up.
Another project was to have a list of all medications. The pharmacists could help fill it out and the physician would know about it, but no one ever looked at it in the health care sector because no one really tackled that as part of the program.
I think it is a very positive thing, but it needs to include the physicians and the pharmacists in the area if you really want to get the best bang for your intervention buck.
Mr. Murphy: It seems to me, then, that some sort of monitoring of that program is required. It's one thing to give $10,000 or $15,000 for these programs and so on, but if it's not working, or if there's a piece missing, then that evaluation should take place and recommendations should be made. I put that forward.
Thank you.
The Chairman: Paul, please.
Mr. Szabo (Mississauga South): Thank you for your presentation. I think it's always a good thing to tell people that they've done a good job when they have, and I think you've done an excellent job in identifying a problem, and also in identifying an opportunity, and making a recommendation. Very often people come here and just try to educate us, but we never get anywhere.
This is important. I think you've given us some powerful statistics with respect to the growth of drugs, and I hope we will incorporate them in our report, Mr. Chairman and committee staff.
I raise it because even the public is seeing some evidence that there is this concern about the rising number of drugs.
There is a vignette that they run on CTV called ``2000 Plus'', sponsored by Chrysler. On the drugs issue they made a statement to the effect that over the past x number of years, 8,000 new drugs were developed and only 1% have any incremental beneficial value. The rest of them are all redundant, repackaged, or reformulated and generally don't do anything more than something that already exists. It is basically a reaffirmation of what you've said.
I consider this to be a complex problem, though. For every complex problem there is a simple solution, and it's wrong. We need a multiplicity of approaches. I think certainly the aspect of harmonizing information to ensure there's not abuse.... But when you consider the problems and costs associated with not using prescription drugs as directed and compound that with the sheer volume, it is impossible.
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So maybe part of the solution is going to have to be to put sunset clauses on some of these drugs, or maybe deal with the introduction of drugs that in fact don't, by any independent criteria, have any new or beneficial effect that doesn't exist already in licensed prescriptions or drugs.
I don't know how we get to this, but I think it has to be driven by the profession to ask why these drug companies are developing all these drugs, coming to me and providing whatever inducements such that 40% of what they spend on drugs, and the pricing of drugs, is promotion. It's promotion to the medical profession. The medical profession is taking this money, or these inducements, to add to the problem.
I guess my question to you is whether there is a role for us to play in terms of putting the pressure on the medical profession itself to push for responsible development of drugs to the extent that they incrementally are beneficial to the population as a whole as opposed to being redundant.
Dr. Tamblyn: First, I want to agree with you that in fact there is no one magic solution here. As someone said last week here in Ottawa, you have to pull 100 levers to fix this problem.
I would also agree that in fact the issue of what you demand as evidence before approving a drug for sale in Canada is a question you need to think about in terms of current policy. Right now most drugs are used on older people. Older people aren't represented in clinical trials for drug approval. So the people who have three or four health problems and take seven medications are definitely not included in clinical trials. Those are the people who are being seen out there.
It's really the drug company that develops the drugs. You can't stop them from developing drugs. But they certainly aren't going to develop drugs that are not going to be approved for market. So it has to do with what criteria you are going to establish to say what is required for a drug to be approved for marketing, or what is required in terms of payment for post-marketing reviews of use of drugs.
This is something that certainly can be specified by the provincial governments themselves, who make decisions about what drugs go into provincial formularies. They can say, we want to see this drug; we want you to essentially contribute to the optimal utilization of this drug in terms of use by both individuals and the physicians prescribing it; and we want to monitor whether or not the benefits and adverse outcomes are evident once it gets into practice, given that maybe all people who might have been users of the drug are not included in the clinical trials for drug approval.
So it's really not the medical profession but the drug industry and regulatory policy at the national level and provincial policy in terms of formulary regulation of what drugs we will insure and what we won't. It's fairly simple to make some changes right at that point.
Perhaps I shouldn't say ``fairly simple''. I'm sure it's very difficult.
Mr. Szabo: It's complex. I understand.
The Chairman: Ms Busto.
Dr. Busto: First of all, I would agree with you and with Dr. Tamblyn that this is a very complex issue. I would also like to make the point I made earlier, that balancing the views of what is good and what is bad about medications and legislation is important. It's true that some medications introduced into the market are ``me too'' medications, as we call them, very similar to what one already has.
On the other hand, sometimes in Canada - I come from a different culture and country - medications that are very effective take a long time to be approved and therefore be beneficial for people. I'm not saying it's bad that we are careful in accepting medications, but sometimes there are two aspects to a coin. Even now, acamprosate, a drug for alcohol dependence, is available in Europe in many countries and has not even started to be tried on the North American public.
So I would like you to keep in mind that this complex issue always has two sides to the same coin, the benefits and the risks. At any point in a decision or in a guideline both should be considered.
The Chairman: Dr. Carter.
Dr. Carter: I'd like to make two points along that line. One is the incredible need for better post-marketing surveillance of drugs in Canada. We've made this point many times, but there is not a good post-marketing surveillance system in Canada. It is in post-marketing surveillance that we discover a lot of things about a drug, such as unexpected adverse effects, and particularly things about its use in people with multiple comorbities. This is very poorly done in Canada; it needs to be done much better.
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The other thing that needs to be done is post-marketing pharmaco-economic studies. When they're introduced, the true spectrum of use of many drugs is not understood. You can't really do pharmaco-economics until you know exactly how a drug is going to be used in the real world, what the age range is, and what the comorbities, etc., are going to be in real use. That is another tremendously lacking thing in Canada, and one on which we need to put a lot more emphasis.
To go along with what Usoa was saying, the other point I'd like to make is about the potential benefits of drugs, as well as their potential side effects. I think it has to be made clear that, particularly with the use of narcotic analgesics in terminal disease, these drugs are probably under-used in Canada, and Canadians are probably suffering as a result of this.
One of the things that you have to realize is that there's something called prescribing chill. It exists. I think there are a lot of chills that have been described. Prescribing chill does exist and we have to take it into account with regard to the complexity of solving these problems, as you were saying, Mr. Szabo. One of the things that physicians have a sense of is that Big Brother is watching them. If they feel these information systems are set up in such a way that they're being watched, and by which there will be a punitive approach taken to their prescribing, then you will see something even more drastic in the way of prescribing chill in this country.
Mr. Szabo: Mr. Chairman, I would be remiss if I didn't ask Robyn this question. Since we do have warning labels on some prescription drugs, do you - or maybe the other panellists - have an opinion on the propriety and relevance or importance of health warning labels on products such as drugs?
Dr. Tamblyn: I think they're absolutely essential, but I don't think they're that useful to people in their current form. They are endless lists of symptoms and possible side effects, and they do not give even the ones that are most likely to happen, the most relevant ones.
Further confusion is created by the fact that you don't even know you're taking two drugs that are the same. They have different names and they come in different shapes, but they're the same drug. So in terms of packaging and whatever else, there definitely is a lot more that can easily be done.
The Chairman: Thank you, Paul.
Remind me after the session to tell you my joke about the one-track mind, will you? Paul loves to ask that question.
Herb.
Mr. Dhaliwal (Vancouver South): I have just two quick questions, Mr. Chairman. I wouldn't mind hearing a comment from the panel on B.C.'s reference-based pricing, which lists the drugs that can be prescribed. I wonder how the medical profession views that. Is it going to have negative or positive effects in terms of prescribing drugs?
My other question is.... I'm not someone who takes medication, because my own personal view is that there's an overuse of medication. People get headaches, and right away they tend to want to go to the medicine cabinet to take a Tylenol or an aspirin. My view has always been that if I have a headache, perhaps I should rest or take some other action. I tend to take very few medicines, if ever. If they have headaches, I think Canadians in general will take an aspirin or a Tylenol because they feel that's the way to deal with it. Personally, I feel that's the wrong way to deal with it; as a society, we've become overdependent on drug use.
My own personal experience is that when I use alternative ways to deal with those things, it's a lot better in the long term. Once people get used to taking an aspirin or a Tylenol for their headache their body almost depends on that and I think you end up creating a bigger problem...from experiencing other people who do that. I think in my whole life I've taken 100 pills, or 150 pills at the most, because I just refuse to take them unless I absolutely have to take the pills.
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I'm sorry, I wasn't here for your presentation. Is there a consensus in the medical community that there is an overuse of drugs? If there is, what is the medical profession doing to deal with the overuse of drugs?
Dr. Carter: It sounds as if that was addressed to me.
First of all, you asked about reference-based pricing. In fact, reference-based pricing is just a drug coverage system. It's a method of co-payment, really. I think it has been misunderstood in the press. It basically changes the method by which the patient is reimbursed for their drugs. The physician is still free to prescribe and the patient is still free to receive what drugs he or she chooses, but the actual coverage, the amount the patient will be reimbursed, is different. I think you have to realize it really is a coverage or a reimbursement or a co-payment system, which through price effects tries to affect prescribing -
Mr. Szabo: That's also going to have an effect on which drugs are being used or prescribed by the doctor, because only a certain number will be paid for. If a patient wants other drugs, they have to pay for them out of their pocket, don't they?
Dr. Carter: The coverage will cover the cost of the least expensive. So if you want a drug that's only slightly more expensive, it's not a big cost to you. If you want something that's very much more expensive, such as omeprazole, yes, you'll have to pay a lot.
Again, in such a system it's really the details that matter: how easy it is to get exemptions, for what reasons, with how much paperwork. These things are very important in the actual effects of such a system, and it's in those details that these systems either work or don't work.
It's very hard to comment. The one that has been introduced in B.C. is actually very much a moving target. It has changed almost monthly since it was introduced. It's hard to make a comment on something where the details are what matters and the details are changing on a regular basis.
I think these systems have the potential for harm and they have the potential for benefit. It all depends on the details.
I don't know if anybody else has any other comments on reference-based pricing.
Dr. Busto: Not on pricing, but I would like to put in a good word on medications. As I said, if the medications we have available are appropriately used, they are tools we didn't have fifty years ago. They have made for tremendous improvements in health, which have been reflected in prolonged life, better quality of life.
I'll give you an example: anti-depressants. Fifty years ago the person who had severe depression was institutionalized for months, years. These days you have effective medications that treat depression very well. Yes, they do have some problems, but if you had a family member who had a severe depression, which is 5% of the population over a lifetime, and you had the choice, should I institutionalize this person or pay $200 a month for the medication, I don't know about you, but I would pay the $200.
The other thing I would like to make a caution on is some of the alternative medications that are so in vogue these days, and I come from the Addiction Research Foundation. They come. You tell a patient, take this medication, or a pharmacy says, this is effective for...blank. They say, oh, no, this is not good for me. Then they walk to the nearest food store and get some valerian tincture. You don't know what is in there. You don't know what strength it is. And they drink the whole thing. These alternative therapies have not been properly tested - most, not all, but certainly not the ones at the food stores - as medications have.
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So it's a very complex issue, one you have to take into account. Not to take a medication is not necessarily ``good''. If you have an infection that is severe, I think I would recommend that you go for the medication. For anxiety, for insomnia, for pain, well, that is a much more complicated issue. For a serious disease, if there is a medication that is effective, I like to speak a bit of good about the benefits these medications have, not necessarily what illegal drugs have. Do you know what I mean? These drugs can be useful. Cocaine now is not useful. It was at one point, but not now.
Mr. Dhaliwal: Dr. Carter, do you have a comment on my second part, overuse, and what the Medical Association is doing about that?
Dr. Carter: First of all, I agree with Usoa that medications have done tremendously beneficial things for our society. I think we have just forgotten - and maybe none of us here is old enough to remember - how our children died of meningitis and tuberculosis. I think you have to remember that it wasn't that long ago that these things happened.
But it is a matter of balance. We have to learn balance. Patients have to learn balance, and society has to learn it. It doesn't help society to be balanced when the advertising industry is basically aimed at increasing consumption. I think that's something we have to recognize. The Tylenol ads on TV drive me crazy.
So I think we have to learn balance as a society, and we have to mature as a society. Drugs in our society have only been around in large quantities, for a large number of uses, for actually a relatively short time in our history. We have to learn to use these things in a balanced way.
I think all of society, not just the medical profession, has the responsibility to evolve this way.
Mr. Dhaliwal: Thank you.
The Chairman: We are now well out of time. I want to thank our witnesses for spending some time with us this morning and giving us the benefit of their expertise.
As you know, we're in the midst of a study reviewing Canada's drug policy. In that context we may have reason to call on your knowledge again. Thank you very much for coming.
I'd ask the committee to stay. We have some other things we'd like to do.
[Proceedings continue in camera]