INTRODUCTION

On 30 October 2013, the House of Commons Standing Committee on Health (“the Committee”) agreed to undertake a study of no more than 10 meetings on the federal government’s role in addressing prescription drug abuse, which would focus specifically on the current scope of the problem and at-risk population groups; best practices for prevention and raising awareness; and promising strategies at the community level.[1] During the course of its meetings, the Committee heard from a wide range of witnesses, including: federal government officials from the Health and Justice portfolios, the Canadian Centre on Substance Abuse (CCSA), provincial government representatives, national health professional organizations, addiction and pain specialists, patient advocacy organizations, pharmaceutical companies and Aboriginal organizations.

This report summarizes the testimony from these meetings and highlights areas where the federal government could take action to address prescription drug abuse in Canada. In line with the study’s terms of reference, the report begins with an overview of the scope of the problem. It then turns to an examination of the federal government’s role in addressing the problem in the following areas based upon witness testimony: regulation of the pharmaceutical supply chain; the National Anti-Drug Strategy; the implementation of the National Advisory Council on Prescription Drug Misuse’s pan-Canadian Strategy, First Do No Harm: Responding to Canada’s Prescription Drug Crisis; and the prevention and treatment of prescription drug abuse among federal client groups, including First Nations and Inuit and federal offenders. The report concludes with the Committee’s observations and recommendations, which identify ways that the federal government could expand the National Anti-Drug Strategy to address prescription drug abuse in Canada in line with the commitments made in the 2013 Speech from the Throne.[2]

IDENTIFYING THE SCOPE OF THE PRESCRIPTION DRUG ABUSE PROBLEM AND POPULATION GROUPS AT RISK

What is Prescription Drug Abuse?

According to representatives from the CCSA, prescription drug abuse can be defined as the non-therapeutic use of prescription drugs.[3] This practice includes the use of prescription drugs for non-medical reasons, and/or the secondary negative effects of prescription drug use that can result even when an individual uses prescription drugs for therapeutic reasons, such as addiction, overdose, and death. Harm may result from therapeutic use of prescription drugs that is not consistent with best practices, either in terms of prescribing for, or treating specific conditions.[4] Individuals gain access to prescription drugs either directly through an authorized health care practitioner, or indirectly from the medicine cabinet of a friend or family member.[5] Prescription drugs can also be obtained through illegal diversion from the pharmaceutical supply chain by individuals or organized crime groups.[6] Illegal diversion techniques can include armed robberies of and break-ins to pharmacies, and the fraudulent use of the health care system such as double doctoring, forgeries of prescriptions and illegal Internet sales.

Identifying the Scope of the Problem

Though there is limited national-level surveillance data available on the scope of prescription drug abuse in Canada, witnesses appearing before the Committee indicated that there is evidence to suggest that this is a growing problem in Canada.[7] Canadians are now the world’s second-largest per capita consumer of prescription opioids behind Americans.[8] Results from the Canadian Alcohol and Drug Use Monitoring Survey (CADUMS) showed that in 2012, an estimated 410,000 Canadians aged 15 years and older reported abusing a psychoactive pharmaceutical, including opioids, stimulants, tranquilizers and sedatives.[9] The Committee also heard that the Youth Smoking Survey, a school-based survey of Canadian youth in grades 6 to 12, found that in 2010–2011, 5% of students reported using psychoactive pharmaceuticals for recreational purposes.[10] Results of these surveys also indicate that prescription drugs are now the third most commonly used substances in both youth and the general population, behind alcohol and marijuana.

The Committee heard that this rise in prescription drug abuse is causing an increase in the number of deaths related to prescription drug use. Between 2006 and 2008, 60% of drug-related deaths in Ontario were attributed to prescription opioids.[11] According to a representative of the Office of the Chief Coroner for Ontario, this trend continues today with more than 500 people dying of opioid toxicity in Ontario each year.[12] If deaths attributed to alcohol and opioids are also included, this number rises to more than 700. He further noted that accidental deaths are more likely to be attributable to opioid overdoses, whereas suicides more often involve other prescription drugs. In Nova Scotia, prescription opioids contributed to 74% of overdoses between 2007–2012, while benzodiazepines and other sedatives are implicated in 62% of cases.[13] Furthermore, the Committee heard that there is an increasing demand for treatment for opioid dependence in some jurisdictions. In Ontario, admissions to publicly funded substance abuse centres rose by 129% between 2004 and 2011.[14] In Nova Scotia, there was a 112% increase over this period in the number of people undergoing withdrawal management for opioid dependency.[15]

A representative of the Canadian Association of Chiefs of Police also indicated that prescription drug abuse is leading to an increase in pharmaceutical-related crime, including pharmacy robberies, prescription drug diversion, breaking and entering, trafficking, double-doctoring, prescription theft/forgery, drug-impaired offences, and thefts committed to fuel the financial needs of persons seeking drugs.[16] The witness further noted that specific data are lacking on the number of crimes related to prescription drugs alone because of a lack of tools to track these crimes in comparison to those driven by illicit drugs.

The Committee heard that while there is much focus on the rise of the abuse of prescription opioids in Canada, such as oxycodone, fentanyl and hydromorphone, other prescription drugs with addiction potential are also of increasing concern, including: stimulants, tranquilizers and sedatives.[17] In particular, Canada has one of the highest rates of per capita use of the stimulant Ritalin in the world, which is increasingly used by college and university students to improve their academic performance.[18] The Committee heard from an addiction treatment centre that a class of tranquilizers and sedatives called benzodiazepines, which includes Zopiclone, Valium, Ativan, Xanax and Serax, are increasingly being identified as drugs of concern among their clients upon intake at the centre.[19] Witnesses also explained that that users shift from abusing one type of prescription drug to another or to other substances such as alcohol or illicit drugs, depending on availability.[20] The representative of the Office of the Chief Coroner for Ontario further stated that prescription drug-related deaths are often the result of mixed drug toxicity, including the combination of a prescription drug and an illicit purchase.[21]

Who is Most at Risk?

Witnesses appearing before the Committee presented the stories of individuals who had been initially prescribed prescription drugs for therapeutic purposes, but this had later led to escalating use, addiction and, ultimately, death from overdose.[22] They noted that the stories of these individuals are all too common and that “prescription drug misuse affects everyone, every community, every demographic. It is not about marginalized populations.”[23] One witness explained that it is difficult to make distinctions among individuals who use prescription drugs for recreational purposes, individuals who use the drugs for therapeutic purposes such as pain management, and individuals who are addicted to these substances, as often the first exposure to prescription drugs is therapeutic.[24] Another witness noted that the term “recreational user” is problematic because many, who are using prescription drugs “off label", are doing so to self-medicate for other reasons.[25]

However, witnesses also indicated that there is evidence to suggest that it is particularly prevalent in certain population groups, including: youth, First Nations, seniors and the offender population. As noted above, prescription drug use is the third most prevalent form of drug abuse among youth at 16.7%, behind 22% for cannabis, and 55% for alcohol.[26] The Committee heard that a review of Health Canada’s Non-Insured Health Benefits program had found that in 2007, 898 opioid prescriptions were dispensed per 1,000 First Nations individuals aged 15 or older living in Ontario.[27] One witness noted that 30% of individuals seeking residential treatment through the National Native Alcohol and Drug Abuse Program reported opiate use, but no distinction is made between illegal opiates such as heroine, or prescribed opiates such as oxycodone.[28] According to Inuit Tapiriit Kanatami, prescription drug abuse is also a growing public and safety concern among Inuit, though little information is available on the extent of the problem in their communities.[29] A recent study by the University of Lethbridge showed that Inuit adolescents living outside Inuit Nunangat[30] are significantly more likely to use prescription drugs than are First Nations, Métis and non-aboriginal youth.[31]

One witness noted that though limited data are available, the aging population may lead to an increasing number of individuals who need treatment for prescription medication-related harms, such as medication interactions and falls resulting from drowsiness or lack of coordination.[32] The Committee also heard that the offender population is also at risk, as 80% of offenders arrive at federal penitentiaries with a history of substance abuse problems, including problems related to illicit drugs, alcohol and prescription drugs.[33] Finally, the Committee also heard that adult women are also potentially an at-risk population group for prescription drug abuse because women tend to be disproportionately prescribed benzodiazepine compared to the male population.[34] Furthermore, deaths from prescription opioid overdoses are increasing at a faster rate among women than among men because these drugs are prescribed in conjunction with benzodiazepines.[35]

What Accounts for the Rise of Prescription Drug Abuse in Canada?

Witnesses appearing before the Committee explained that several factors have contributed to the rise of prescription drug abuse in Canada.[36] First, though prescription opioids have commonly been used in the treatment of cancer and in palliative care settings, the drugs became increasingly available in the 1990s for the treatment of chronic non-cancer pain, such as back pain and arthritis. The Committee heard that inappropriate prescribing practices are another factor that has led to increased use of prescription drugs. Health care practitioners, including those from the College of Physicians and Surgeons of Ontario, have acknowledged that they lack knowledge and training for pain management, including knowledge of toxicity of prescription pain medication, as well as dosage requirements. Consequently, some Canadians receive prescriptions for inappropriate or excessive quantities of these medications without adequate information or follow-up from their health care team. In addition, the Committee heard that due to an overall lack of control systems in place regarding the marketing of pharmaceuticals in Canada, physicians faced some fraudulent and aggressive marketing practices from some of the manufacturers of these drugs, which led to inappropriate prescribing practices.[37] Consequently, one witness recommended that a “firewall” be put in place between industry, prescribers and patients.[38]

Another factor includes restrictions on the investigation of prescription drug use because of health privacy legislation.[39] Finally, the Committee heard that Canadians lack awareness of the harms related to the use of prescription drugs, which they commonly perceive as safe. This lack of awareness in turn affects consumer practices related to use, storage and disposal of these medications.[40]

THE FEDERAL ROLE IN ADDRESSING PRESCRIPTION DRUG ABUSE IN CANADA

A. Preventing Prescription Drug Abuse through the Regulation of the Pharmaceutical Supply Chain

A Health Canada official appearing before the Committee outlined the federal government’s role in preventing prescription drug abuse through its regulation of the pharmaceutical supply chain.[41] He explained to the Committee that under the Food and Drugs Act and its regulations, Health Canada is responsible for ensuring the overall safety of drugs on the market, including providing safeguards to address the potential for their misuse. Under the Act, a new drug will be issued a market authorization only if Health Canada determines that the drug demonstrates an acceptable level of safety, substantial efficacy and high quality. Based on an analysis of information provided to the department by the drug’s manufacturer, departmental scientists determine whether the data support the approval of the drug and whether the drug should be available by prescription only.

The department also reviews the addiction and abuse potential of new drugs based on studies that assess whether the drugs produce acute effects such as euphoria, or “drug-liking” effects that could lead to addiction or abuse.[42] The witness further noted that Health Canada provides guidelines to manufacturers for the study of certain classes of drugs that are already known to be potentially addictive, such as opioids, stimulants, depressants, cannabinoids and nicotine-like compounds. A drug with significant risk of addiction or abuse is approved only if there are substantial data to support its efficacy in the treatment of serious conditions.

As part of the market approval process, the Committee heard that the product monograph, a scientific document that describes a drug’s properties, claims, indications and conditions of use,[43] must also include information on the drug’s potential for addiction and abuse.[44] The final product monograph, which is produced by the manufacturer or drug sponsor and approved by Health Canada, must advise physicians to prescribe and handle such drugs with caution, assess patients for their clinical risk for abuse or addiction prior to prescribing the drug and routinely monitor patients for signs of addiction and abuse. The product monograph must also include information for consumers, which advises them to take the medication only as indicated by the treating physician, to inform their doctor if they have questions or concerns about addiction or abuse, and to keep the medication safe and not provide it to others, as it may lead to serious harm, including death.

In addition, the department may also require that manufacturers implement a risk management plan that could include monitoring of events related to abuse and addiction once the drug is on the market, as well as educational materials for health care professionals and patients.[45] A representative from the Canadian Generic Pharmaceutical Association further elaborated that these risk management plans, developed in consultation with Health Canada, outline how the risks of the drugs in question will be minimized in patients, as well as include plans for studies and other activities to gain more knowledge about the safety and efficacy of the medications.[46]

The Committee heard that the safety of a drug is also monitored once it is on the market. A representative from the Canadian Generic Pharmaceutical Association explained that under the regulations of the Food and Drugs Act, all pharmaceutical companies are required to monitor the use and effect of a given medication and detect, assess, and prevent any adverse reactions, or any other medicine-related problems.[47] He also noted that under the regulations, pharmaceutical companies are required to report serious adverse drug reactions to Health Canada, as well as prepare annual safety reports.

The Committee heard that Health Canada monitors the safety of a drug once it is on the market.[48] A Health Canada official indicated that “as new information about side effects emerges, the product monograph is updated to inform health care professionals and patients about the new safety information. The risk management plan can also be altered to address changes in risks, or the drug can be removed from the market if the experience with the drug shows that its benefits no longer outweigh its risks.”[49]

Finally, the Committee heard that the federal government also attempts to prevent prescription drug abuse through the Controlled Drugs and Substances Act (CDSA) and its regulations. The CDSA is a legislative framework for the control of substances that can alter mental processes and that may cause harm to the health of an individual or society, when used illicitly or when diverted to an illicit market.[50] The CDSA prohibits activities such as the production, sale and possession of these substances, unless authorized for legitimate medical, scientific or industrial purposes, such as their use in prescription drugs. The Act’s regulations include provisions that aim to prevent the diversion of prescription drugs that contain controlled substances from the pharmaceutical supply chain, such as reporting and record-keeping requirements and security measures for licensed wholesale dealers and pharmacists. An Inspector from the Royal Canadian Mounted Police (RCMP) explained that the CDSA also includes offences for fraudulent use of the health care system to obtain prescription drugs, such as “double doctoring”[51] which refers to an individual seeking a prescription for a narcotic from a health care practitioner without informing the practitioner about any other prescription or narcotic received from another health care practitioner within the last 30 days.[52] The Committee heard from federal officials that Health Canada works across the pharmaceutical supply chain to verify compliance with the CDSA and its regulations.[53]

During the course of its study, the Committee heard testimony from other witnesses who identified ways that the federal government could further strengthen its regulation of the pharmaceutical supply chain to prevent prescription drug abuse. With respect to the Food and Drugs Act, some witnesses felt that greater weight needs to be placed on the addictive potential of a drug during the market approval process. One witness suggested that this could be achieved through the establishment of an expert committee on “drug and patient safety” at the federal level that would assist Health Canada in its review of drugs that have the potential to be highly addictive.[54] One witness recommended that Health Canada deny the market approval of a product produced by either a generic or a brand-name pharmaceutical company, if it manufactures both an addictive drug and a drug for the treatment of addiction.[55]

Some witnesses appearing before the Committee recommended that “tamper-resistant” formulations be required for the approval of both generic and brand-name drugs with addiction potential because such formulations may deter the abuse of these drugs.[56] The Committee heard that one of the challenges with newer opioid formulations that have been approved, such as the brand-name drug OxyContin, is that the drugs were designed to release their active ingredients slowly over a relatively long period.[57] However, OxyContin can be crushed and either snorted or injected, which has led to overdoses among patients who may have received the drug through a nasogastric tube and in individuals who have abused the medication.[58] A representative of Purdue Pharma Canada, the manufacturer of OxyContin, explained that its new formulation, called OxyNeo, is made with an abuse-deterrent formulation, which has been shown in studies to reduce the oral abuse of this drug by 33% and reduce the non-oral abuse of the drug (injection, snorting and smoking) by 73%.[59] However, the representative also noted that tamper-resistant formulations will not prevent addiction to the drug and do not represent a “silver bullet” solution to the problem of prescription drug abuse.[60] Similarly, other witnesses noted that while tamper-resistant formulations have been shown to reduce the risks of overdose, they do not reduce the abuse of the drug entirely, as much of the abuse continues to occur orally.[61]

Moreover, some witnesses were of the view that additional regulatory mechanisms need to be in place for the approval of generic versions of drugs whose brand name equivalents had been shown to be highly addictive.[62] For example, the Committee heard that when the patent expired on the drug OxyContin, Health Canada authorized six companies to produce a generic version of the product, oxycodone, despite its well-known addiction potential.[63] Under the Food and Drugs Act regulations for the market approval of generic products, Health Canada considers only scientific evidence related to safety, efficacy and utility under its recommended conditions of use for the intended patient population.[64] While Health Canada does examine the risks of the generic drug, it does so only in the context of the intended use of the drug.[65] However, other jurisdictions, in particular the United States, allow for the examination of evidence related to abuse potential of the generic drug by the broader public or outside the drug’s intended population.[66] However, these witnesses felt that the broader social and health-related harms associated with OxyContin, as well as other addictive drugs, need to be taken into account in the approval of their generic versions, in addition to requirements for tamper-resistant formulations as noted above.[67]

Furthermore, the Committee heard that Health Canada could also review and strengthen regulatory requirements for product monographs and labels of prescription drugs, as well as manufacturers’ risk management plans.[68] One witness explained to the Committee that many product monographs and labels for prescription opioids and other addictive drugs are currently inaccurate with regards to their risks and addiction potential.[69] Consequently, the Committee heard that both the labels and product monographs for these drugs needed to be reviewed and updated by Health Canada, in consultation with independent experts if necessary.[70] A member of the National Advisory Council on Prescription Drug Misuse’s (NACPDM) Legislation and Regulation Committee therefore recommended that Health Canada require that the labels for all prescription opioids, including pain medications and treatment for addictions, carry a warning stating that there is a possibility of addiction, misuse or death with the use of these drugs, even when used as prescribed.[71] He further recommended that the labels for this class of drugs be required to indicate that they be used for “severe pain” rather than “moderate” pain, which is the use currently indicated. The witness also recommended that the label be required to include the results of clinical trials for the drug in question. The same witness suggested that the monographs should undergo a mandatory review by Health Canada every two years.[72] Another witness noted that an inquest on prescription opioid misuse recommended that dose recommendations for these products be included in monographs.[73]

In terms of manufacturers’ risk management plans, one witness recommended that Health Canada identify and develop effective risk mitigation strategy standards and models that pharmaceutical companies and industry players would be required to adopt.[74] The witness further suggested that manufacturers be required to report annually on the implementation of these strategies with penalties for non-compliance.

Finally, some witnesses recommended that Health Canada needs to improve its oversight of the marketing practices of pharmaceutical companies.[75] They explained that the prescription drug abuse problem emerged in Canada in part because of the marketing practices of pharmaceutical companies, in particular those of Purdue Pharma.[76] Dr. Navindra Persaud told the Committee that Purdue Pharma’s marketing strategy for its prescription opioids, such as OxyContin, focused on misleading physicians about the abuse potential of its new opioid formulations, given the physicians’ traditional resistance to prescribing these drugs because of the risk of addiction. Purdue Pharma pled guilty to fraudulent marketing practices as part of a class action suit in the United States in 2007. This guilty verdict resulted in the company paying a fine of $634.5 million.[77]

However, the Committee heard that Purdue Pharma has not faced consequences in Canada despite having made similar false claims in this country.[78] Dr. Persaud explained that Health Canada does not proactively monitor the pharmaceutical industry’s claims about its products. Therefore, Purdue’s distortion of information about the addiction potential of prescription opioids remained unrecognized and no action was taken, even after the 2007 verdict in the class action suit in the United States. Dr. Persaud therefore recommended that Health Canada proactively regulate the marketing of medications that may be harmfully misused. The regulations could include proactively monitoring companies’ advertising claims and banning certain practices, such as physician office visits by company representatives and the sponsoring of the education and training of health care providers.[79] Another witness appearing before the Committee further recommended that the federal government make it an offence under the Food and Drugs Act for a manufacturer to mislead the regulator with regards to the addiction potential of a drug, or not to provide the department with all available clinical trial data.[80]

The Committee also received testimony about how the CDSA could be updated to address prescription drug abuse. A representative of the National Association of Pharmacy Regulatory Authorities (NAPRA) suggested that the CDSA needs to be updated and redesigned to reflect the current health care environment, including the different health care practitioners’ responsibilities in relation to prescription drugs that contain substances controlled under the CDSA, as well as new technologies that are available to meet the reporting requirements of the legislation.[81] She further proposed that regulations under the Act need to be updated to promote information sharing between federal and provincial/territorial regulatory and law enforcement bodies in instances where prescription drug abuse is suspected. She also suggested that Health Canada place drugs with addiction potential more quickly on the schedules of the CDSA, because otherwise there are delays in the implementation of the control activities to monitor these drugs at the provincial and territorial level.

Another witness recommended that the federal government examine whether the conditions for exemptions under Section 56 of the Act, which allow health care providers to prescribe drugs that contain controlled substances, such as methadone, in the treatment of addictions, pose additional barriers to treatment for addictions.[82] He further suggested that this section of the Act could also be examined to see whether it could include restrictions for practitioners wanting to prescribe opioids beyond the limit of 200 mg/day, which is the “watchful dose” recommended in the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain.[83]

Finally, the Committee heard from witnesses that Health Canada needs to enhance its efforts to monitor compliance with the CDSA across the pharmaceutical supply chain. A representative from NAPRA explained that in the 1980s and 1990s, there was a national oversight program that monitored prescriptions for controlled substances whereby all pharmacists in the country were required to submit reports of their sales of these products to the federal government. The information was used to identify behaviours that might suggest inappropriate prescribing behaviour or abuse of the health care system[84] and to launch investigations where necessary. However, the Committee heard that this type of monitoring is no longer occurring. Pharmacists told the Committee that there is a need for national guidelines for the disposal of prescription drugs regulated under the Act, as well as verification measures to ensure that these substances are disposed of properly.[85]

B. The National Anti-Drug Strategy

Federal officials appearing before the Committee outlined the National Anti-Drug Strategy (Strategy), including efforts to expand the Strategy to address prescription drug abuse. A representative from Justice Canada explained that the Strategy “aims to contribute to safer and healthier communities through co-ordinated efforts to prevent use, treat dependency, and reduce production and distribution of illicit drugs.”[86] With $515.9 million in allocated funding for 2012–2017, the Strategy consists of three action plans: prevention, treatment and enforcement. Health Canada and Public Safety Canada are responsible for the prevention and treatment plans, while Public Safety Canada is responsible for the enforcement plan.[87] The Strategy also involves the collaboration of 12 federal partner departments.

Though the Strategy focuses on illicit drugs as defined in theCDSA, the Committee heard that the federal government committed in the 2013 Speech from the Throne to expand the policy mandate of the Strategy to include the growing problem of prescription drug abuse.[88]

Federal officials appearing before the Committee outlined departmental initiatives already underway to address prescription drug abuse. A representative from Public Safety Canada explained that the Department hosted a national workshop on the illicit use of pharmaceuticals in June 2011 to increase the overall understanding of pharmaceutical product misuse from a public safety perspective.[89] The department also invested in a pilot project in the Niagara region to hold a prescription drop-off day in May 2012, which allowed for the safe disposal of unused or unfinished medications in order to limit their possible misuse. The success of this initiative led to the creation of a National Prescription Drug Drop-Off Day held in May 2013 in conjunction with the Canadian Association of Chiefs of Police, which resulted in just over two tons of pharmaceutical products being collected.[90] The department has also produced a handbook outlining prescription drug return initiatives in Canada.[91] Public Safety Canada and Health Canada also successfully put forth a resolution on behalf of Canada that was adopted at the United Nations Commission on Narcotic Drugs, which called on member states to promote initiatives aimed at the safe, secure and appropriate disposal of prescription drugs, in particular those containing substances under international control.

The Committee heard that the RCMP works collaboratively with domestic and international partners to identify, prevent and detect prescription drug abuse.[92] RCMP Inspector Jean Cormier told the Committee that the investigation of abuse or the diversion of prescription drugs is challenging and complex. In order to address some of the challenges, increased information sharing among different private and public partners is necessary, along with providing officers with specialized education and training in the investigation of illicit activities related to prescription drugs.

A representative from Health Canada explained that its public awareness campaign “DrugsNot4Me,” under the National Anti-Drug Strategy had been very successful in raising awareness among youth and their parents about the dangers of illicit drugs.[93] The witness further stated that as a result of this campaign, youth are now more likely to say that they would refuse to take illegal drugs, and parents were engaging in discussions with their teens about the risks associated with prescription drugs. The witness told the Committee that work is now under way to see how the success of this program and others under the Strategy could be built upon to address prescription drug abuse.

Witnesses appearing before the Committee welcomed the inclusion of prescription drug abuse in the National Anti-Drug Strategy.[94] They also expressed support for initiatives that the federal government had already undertaken to address prescription drug abuse and in particular, the National Prescription Drug Drop-Off Day.[95] Some witnesses, including Mr. Donald MacPherson of the Canadian Drug Policy Association and Dr. Lisa Bromley from the Ontario Ministry of Health and Long-Term Care’s Narcotics Advisory Board and the Canadian Nurses Association (CNA), recommended that harm reduction be reinstated in the National Anti-Drug Strategy.[96] A representative of the CNA explained that harm reduction, a public health approach that promotes safety while preventing death and disability, has been shown to be an effective method of supporting individuals still engaged in active or decreasing drug use. The witness further recommended that the Strategy be reviewed every 10 years by the Office of the Auditor General to ensure it is meeting its public health objectives.[97] Other witnesses were also supportive of the inclusion of initiatives aimed at preventing or reducing the harms associated with prescription drug abuse in the National Anti-Drug Strategy.[98] However, they did not feel that there should be an expressed focus on harm reduction in the Strategy, as the term remains controversial and divisive, and such a focus could undermine public health efforts to address prescription drug abuse in the first place.[99]

C. Implementation of a Pan-Canadian Strategy to Address Prescription Drug Abuse

The Committee heard from witnesses that the federal government needed to support the implementation of a pan-Canadian strategy to address prescription drug abuse. Many witnesses appearing before the Committee endorsed a pan-Canadian strategy that had already been developed by the CCSA and 20 other partners, entitled First Do No Harm: Responding to Canada’s Prescription Drug Crisis. Representatives from the CCSA explained that the organization had brought together health professionals, patients, families, members of First Nations communities, law enforcement representatives, regulatory bodies, the pharmaceutical industry and researchers to form the NACPDM, whose task was to develop a pan-Canadian strategy to address this growing concern. Representatives of the CCSA also explained that federal government departments were also involved in the development of the strategy, including Health Canada, Public Safety Canada, the Department of National Defence and Justice Canada.

The Committee heard that the CCSA and the Minister of Health launched the strategy in March 2013, which lays out 58 recommendations in the following areas: prevention, education, treatment, monitoring and surveillance, enforcement, legislation and regulations, and knowledge exchange. Representatives from the CCSA explained that since its launch, they had put together five teams to implement different components of the strategy, which are composed of experts that had contributed to the development of the initial recommendations. To move forward in the implementation of the strategy, the CCSA indicated that it requires additional financial resources from the federal government to support the implementation of the strategy, including coordinating its working groups. The representatives noted that these funds would serve to leverage funds from other levels of government, professional organizations and the non-profit sector to support the implementation of the strategy. The CCSA has requested $1 million per year from the federal government for the implementation of the strategy over a 10-year period and has committed to reporting on progress annually. Representatives of the CCSA further noted that as an agency created by an Act of Parliament to address substance abuse in Canada by bringing together different partners and levels of government, it is well-placed to coordinate the implementation of the strategy,

In addition, witnesses appearing before the Committee identified the role that the federal government could play in implementing specific components of the pan-Canadian strategy, including prevention, monitoring and surveillance, treatment and enforcement. The witnesses also highlighted promising initiatives in these areas and identified other aspects of addressing prescription drug abuse that could be included as part of a pan-Canadian strategy. This testimony is outlined in the sections below.

1. Prevention

Raising Awareness

In terms of prevention of the harms associated with prescription drug abuse, the Committee heard that Health Canada and the Public Health Agency of Canada could take the lead in developing, implementing and evaluating prescription drug-related social marketing campaigns that would include information about: the benefits, harms of use as prescribed and of non-medical use; signs and symptoms of misuse, addiction and overdose; safe storage and disposal; other strategies to prevent harms; and wellness promotion and alternatives to pain medications.[100] The Committee heard that public awareness campaigns should be targeted at different audiences including prescribers so that they understand the impact and extent of the issue, as well as patients, vulnerable population groups such as seniors, First Nations, and the general population.[101]

Witnesses appearing before the Committee also identified some promising strategies at the community level that have been successful in promoting awareness of prescription drug abuse among parents and youth. For example, one community is distributing lockboxes to parents to ensure that they store their prescription medications safely away from their children.[102] The lockbox helps parents keep track of their medications, as well as prompts them to have a discussion with their children about prescription drug abuse. The Committee heard that lockboxes should be distributed in communities, or parents should be encouraged to lock up their medications to ensure that they are not accessible to children.[103]

Prescribing Practices

With respect to both the prevention and education components of the strategy, the Committee heard that the federal government had a role to play in promoting appropriate prescribing practices among health care practitioners for prescription drugs with addiction potential. Health care practitioners noted the challenges they face in prescribing opioids for pain management because of the many complex factors that are involved in making prescribing decisions, such as how the patient reacts to a medication; his or her medical history; which drugs were prescribed when the patient was in hospital; the patient’s income level; whether the patient has a drug benefit plan; as well as his or her individual preferences, which are often influenced by other people such as parents and/or daycare providers for children.[104] Other prescribing challenges include the increasing number of patients with multiple chronic conditions.[105]

Furthermore, health care practitioners explained that while they have training in prescribing opioids to treat conditions, they lack the knowledge and training to prevent the negative consequences or complications arising from their prescribing, which in turn has led to adverse drug events.[106] For example, a 2011 study on Ontario primary care physicians’ experiences found that though the majority were confident in their prescribing of opioids, 42% reported that at least one of their patients had experienced an adverse event usually involving oxycodone and 16.3% were unaware if their patients had experienced an adverse event.[107]

The Committee heard that several initiatives are underway to provide health care practitioners with guidance in prescribing opioids in order to ensure that patients have access to these medications, but health care practitioners are also able to prescribe them in a way to minimize their potential harms. For example, the Committee learned about the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain, an internationally validated evidence-based guideline for the appropriate use of opioids.[108] It establishes a prescribing limit, or watchful dose of 200 mg/day; prescribing beyond this limit requires careful monitoring and follow-up by a health care practitioner.[109] The Guideline also includes tools to screen for whether the individual is at risk for developing an addiction.[110] The Committee heard that the Guideline could provide regulators and others with a standard of care against which to evaluate the prescribing practices of individual physicians.[111] In addition, the Guideline is also supported by an opioid manager tool, which helps educate health care practitioners in the appropriate use of opioids.

One witness highlighted how the community of Inverness, Nova Scotia had used the Guideline to support the development of community-wide intervention strategy aimed at addressing prescription drug abuse and diversion.[112] The Guideline was used as the basis to promote a change in prescribing practices among health care professionals in the community, as well as provide support to pharmacists and law enforcement in their efforts reduce diversion related health care interactions and criminal activity.

While health care practitioners said that the Guideline is a step in the right direction, they also explained that there are many of these types of guidelines available and some of them provide conflicting information and are difficult to navigate.[113] Consequently, efforts are needed to develop tools to translate the guidelines into practice. The Committee heard that there is a role for government to play in assisting the dissemination of this type of information.[114] One witness underscored the need for increased guidance and accountability in the prescribing of not just opioids, but benzodiazepines as well.[115]

In addition to guidelines, the Committee heard that electronic prescribing networks are also being developed to help connect different health care practitioners in fields such as mental health, pain management, addictions, who can be consulted with when family physicians are making prescribing conditions.[116] Finally, the Committee heard that there is a need to support continuing education for health care practitioners, including the development of curricula that focus on the harms associated with the use of different medications.[117]

To address these issues related to prescribing practices, the Committee heard that the NACPDM had recommended in their strategy that Health Canada, “establish a pan-Canadian task force of health care providers, policy planners, researchers, industry representatives and members of the public to: encourage provincial regulatory colleges to develop and implement policies that promote appropriate prescribing practices.”[118] The Canadian Medical Association further recommended a nation-wide strategy to support optimal prescribing and medication use, which would include: educational programs for health professionals, point-of-care tools and special educational supports, such as academic detailing or online communities of expertise, to mentor prescribers and provide guidance, as well as public education to address the safe use of medication.[119] The Canadian Nurses Association also recommended that the federal government support the educational and practice needs of health care providers by encouraging the development of evidence-based information about prescribing practices that could be used in the prevention and treatment of prescription drug abuse.[120]

Overdose Prevention

Witnesses explained that the Strategy also proposed that the federal government, as well as provincial and territorial governments, take the lead in developing and promoting “risk-reduction programs for individuals who use prescription drugs in a manner that places them at increased risk of adverse consequences.”[121] In particular, witnesses stressed the importance of opioid overdose prevention strategies for both prescription and illicit opioids.[122] According to one witness, the first step in this area would be a public awareness campaign highlighting that giving or selling opioids to another person could lead to an opioid overdose since an opioid dose may be safe for the person to whom it is prescribed, but could cause an overdose in another person who is not used to that dosage amount.[123]

Many witnesses explained that a comprehensive public approach to addressing overdose deaths from both prescription and illicit opioids would also include increasing access to naloxone.[124] According to witnesses, naloxone is a safe, highly effective chemical compound that reverses the effects of opioids, but is not psychoactive or addictive.[125] The Committee heard that community-based take-home naloxone programs help people prepare in the event of an opioid overdose by providing training to prevent, identify and respond to an overdose.[126] Currently, there are take-home naloxone programs in Alberta, Ontario and British Columbia. The Committee heard that the program run by the British Columbia Centre for Disease Control has resulted in 55 overdose reversals since it was first initiated in 2012.[127] Meanwhile, studies evaluating take-home naloxone programs in the United States have shown that these programs have been linked to a 34% reduction in drug deaths and bystanders have used naloxone to reverse more than 10,000 opioid overdoses.[128]

However, one witness noted that these programs are hindered by the cost of the medication and the fact that it requires a prescription under Schedule F of the Food and Drugs Act, which means physicians are concerned about prescribing a drug that will be administered not by the person named on the prescription, but by a third party.[129] The witness noted that Health Canada could facilitate access to naloxone by rescheduling the drug to make it available without prescription, as well as encourage pharmaceutical companies producing the drug to reduce its costs.[130] In addition, he recommended that the federal government amend the Controlled Drugs and Substances Act to provide protection from arrest and prosecution for drug crimes for individuals who call 911 for help in a drug overdose event, as well as the development of a monitoring system that would track overdoses. Finally, the witness noted in a written follow-up to the Committee that the inclusion of elements for the prevention and treatment of overdose in national drug policies was supported by a resolution passed by members of the UN International Narcotics Control Board.[131]

2. Monitoring and Surveillance

Witnesses highlighted the importance of the federal government supporting the development of a pan-Canadian monitoring and surveillance system for prescription medication. The Committee heard that there is a need for pan-Canadian comprehensive monitoring and surveillance system to identify the extent of prescription drug abuse in Canada, including the numbers of people who are affected and the impact of the problem.[132] Currently, there is very little information available and what data does exist comes from different sources and parts of the country.[133] As a consequence, there is no systematic view of the problem or routine surveillance.[134] Health care practitioners also explained that there is need for an interoperable real-time monitoring and surveillance system to prevent the inappropriate prescribing of medications and abuse of the health care system to obtain prescription drugs.[135] For example, the Committee heard that the absence of real-time data available through a pan-Canadian interoperable system means that health care practitioners are unable to look up the medical history of a patient to determine whether he or she has received the same prescription from another practitioner from within the same community or from another jurisdiction, in order to prevent double doctoring.[136] Finally, the Canadian Association of Chiefs of Police articulated that a pan-Canadian prescription monitoring program is critical for law enforcement to have the data necessary to investigate situations where abuse of the health care system may be occurring.[137]

In addition, witnesses identified the steps that the federal government could take to promote the development of a pan-Canadian prescription drug monitoring system. First, the federal government could evaluate the prescription monitoring programs that currently exist in some provinces to identify best practices, which could be used to support the development of these systems across the country.[138] Witnesses highlighted some examples of prescription monitoring systems in different jurisdictions that could be considered good examples of these types of programs. For example, Alberta and British Columbia have developed Triplicate Prescription Programs, which monitor the prescribing of medications by having three-part prescription forms, where the practitioner retains a copy of the prescription, one is sent to the dispenser, and a third is sent to the regulatory body.[139] Nova Scotia also has a prescription drug monitoring program that is electronic and accessible 24 hours day.[140] Furthermore, the program electronically integrates physicians with pharmacies and law enforcement agencies. In addition, the province has introduced a High-Volume Prescriber Program through its prescription drug monitoring system, which aims to identify and educate those physicians who prescribe high amounts of monitored drugs in comparison to their peers.[141]

Witnesses recommended that the federal government examine prescription drug monitoring programs in other jurisdictions to identify best practices. In particular, they highlighted the RADARS^® system in the United States, which is run by an independent health authority, but funded by the pharmaceutical industry.[142] The system integrates different sources of data, including population surveys, poison control centre data, coroners’ data, as well as surveys of clients in treatment centres, to determine abuse, misuse and diversion trends.[143] In line with the RADARS^® model, one witness recommended that all manufacturers of prescription drugs, used either in the treatment of pain or addictions, be required to contribute funding to the development of a pan-Canadian surveillance system.[144]

Second, the Committee heard that the federal government could work with the provinces and territories to develop common standards for prescription drug monitoring systems across the country, including types of data included, definitions and terminology, as well as common indicators to monitor, to ensure that the data collected across Canada are comparable.[145] Finally, witnesses explained that the federal government could also work towards ensuring that prescription drug monitoring systems are interoperable, which would allow data flow across different jurisdictions.[146]

3. Treatment

Witnesses identified improving access to multi-disciplinary pain management services and addiction treatment services as being critical in addressing prescription drug abuse across Canada. The Committee heard that a lack of access to multi-disciplinary pain management services, particularly in rural and remote areas, means that physicians and patients rely on prescription drugs only to treat pain, instead of non-pharmacological options such as physiotherapy, occupational therapy and psychology.[147] In addition to geographical obstacles, the Committee heard that access to multi-disciplinary care teams for pain management is hindered by the fact that access to these pain-relieving modalities is not covered by public health care plans.[148]

Further, a representative from the Canadian Pain Coalition explained that 45% of people suffering from moderate to severe pain in Canada believe that there is nothing to help them with their pain, which could lead them to take more medication than required out of desperation.[149] The Committee heard that the federal government could play a role in this area by supporting initiatives being undertaken by the DeGroote National Pain Centre and the Canadian Pain Coalition aimed at raising awareness among patients about the benefits, risks and realities of pain management, as well as promoting the patients’ engagement in the management of their condition. This awareness campaign in turn could be done as part of a larger national pain strategy that would also support research into pain management.[150]

Witnesses also explained that there is a need to improve access to addictions treatment, in particular treatment programs that offer opioid substitution therapy, including methadone and buprenorphine (Suboxone) therapy.[151] The Committee heard from witnesses that methadone can be very effective in treating addiction in certain populations, but it also carries risks of addiction and therefore, physicians must have special training before prescribing it.[152] According to witnesses, buprenorphine is almost as effective as methadone, but has fewer risks and therefore can be prescribed by family physicians who do not have a licence to prescribe methadone, making it more accessible to smaller communities whose physicians may not be licensed to prescribe methadone.[153] The Committee was told that federal, provincial and territorial governments could promote access to these addiction treatments by providing coverage of them on through their drug plans.[154]

4. Enforcement

Witnesses told the Committee that efforts are already underway to implement the enforcement component of the First Do No Harm: Responding to Canada’s Prescription Drug Crisis strategy. A representative from Public Safety Canada explained that it is in the process of developing a plan to implement the recommendations made under the enforcement plan in collaboration with the Canadian Association of Chiefs of Police[155] who explained that, in line with the recommendations of the Strategy, it is undertaking a study to determine the extent of the impact of prescription drugs on law enforcement resources and public safety, which is being supported by Public Safety Canada.[156] The Association is also raising awareness of the issue among law enforcement and justice bodies, and promoting safe storage and disposal of medications by holding another National Prescription Drug Drop-off Day on 10 May 2014. Further, the Association is working towards identifying gaps in tools or training for criminal justice professionals to address the illicit use of prescription drugs more effectively. It is also reviewing practices in death investigations to ensure that they are conducted in an evidence-based and consistent manner. Finally, the Canadian Association of Chiefs of Police is also identifying and addressing barriers to accessing and sharing information related to prescription drug abuse.

5. Combatting the Stigma of Addiction

Though not a specific component of the First Do No Harm: Responding to Canada’s Prescription Drug Crisis strategy, witnesses appearing before the Committee stressed the importance of combatting the stigma faced by individuals who are addicted to prescription drugs.[157] The Committee heard that the general public, health care professionals and law enforcement officials lack knowledge and awareness of addiction as a chronic disease of the motivational system in the brain, as well as the role of opioid substitution therapy in its treatment.[158] This lack of awareness of addiction as brain disease means that individuals who become addicted to prescription drugs and other substances experience negative judgements from others and feel ashamed of their illness.[159] They are therefore reluctant to seek treatment. In addition, they face barriers to treatment within the health care system because of the lack of understanding that health care providers have of the disease and how it should be treated.

In order to address this issue, the Committee heard that there is a need for a public awareness campaign which would both raise awareness of the nature of addiction, as well as celebrate stories of recovery from addiction.[160] Representatives of the Orchard Recovery Centre recommended that the federal government develop such a campaign in consultation with addiction experts, as well as with individuals in recovery. This public awareness campaign could also include support for National Recovery Day, an event that currently takes place in 12 cities across the country, which celebrates individuals who have recovered from addiction and the families that support them. In addition, the Committee heard that there is a need to support individuals recovering from addiction with back-to-work programs that provide the skills and training necessary to reintegrate individuals into the workforce and provide them with the financial means to continue in their efforts to maintain their sobriety.[161]

D. Preventing and Treating Substance Abuse in Federal Client Groups

The Committee’s study also focused on the federal government’s role in addressing prescription drug abuse in its client groups, in particular, federal offenders and First Nations and Inuit communities. The sections below summarize the testimony that the Committee received in these areas.

1. Federal Offenders[162]

According to its Commissioner, the Correctional Service of Canada (CSC) is responsible for 22,762 offenders, 15,056 of whom are incarcerated. The Committee heard that approximately 80% of offenders who arrive at federal penitentiaries have a history of substance abuse, and many with more than one substance. Moreover, approximately 50% of offenders committed crimes where drugs or alcohol were a factor. The Commissioner explained that these trends have also been consistent over time.

The Committee heard that CSC addresses this issue in three main ways. First, steps are taken by front-line staff to reduce the supply of illicit drugs within correctional facilities through drug-detector dogs and enhanced security intelligence. Second, the department makes effort to provide inmates with a high level of medical care by ensuring that they have access to prescription medication, but also take measures to reduce the risk for the abuse of medications with addiction potential. CSC’s drug formulary, which provides a list of medications that CSC is prepared to provide to federal offenders when medically required, either excludes medications that are high risk, or places restrictions on how they are prescribed and administered. It also provides information on available alternates, dosage requirements, and durations for prescriptions.

Finally, the department also provides drug treatment and substance abuse programs to assist offenders in their rehabilitation and in addressing the criminal risks associated with substance abuse. The Committee heard that CSC treatment programs, considered to be among the best case-managed OST programs in the world, include opioid substitution therapy (e.g., methadone). The CSC also ensures that offenders have access to maintenance programs once they enter the community. According to the Commissioner, up to 63% of offenders completing the substance abuse treatment programs did not go on to commit a new offence or violent offence.

2. First Nations and Inuit

The Committee heard from a Health Canada official that the Department supports prescription drug abuse prevention and treatment programs in First Nations and Inuit communities.[163] According to the Health Canada official, the department invests approximately $92 million annually in addictions and prevention and treatment programming. This funding provides support for a network of 55 treatment centres, as well as drug and alcohol prevention services in over 550 community-based prevention programs through the National Native Alcohol and Drug Abuse Program (NNADAP) and the National Youth Solvent Abuse Program (NYSAP). The official also noted that in 2013–2014, the Department is working in partnership with the Ontario Ministry of Health and the Chiefs of Ontario to support First Nations communities in Ontario in addressing prescription drug abuse, where the problem is particularly acute. He said that Health Canada is investing $2 million in support of these efforts.

In addition, Health Canada has introduced measures in the Non-Insured Health Benefits (NIHB) program, an extended health benefits program for First Nations registered under the Indian Act, and Inuk recognized by Inuit Land Claim Organizations,[164] regardless of where they live, which provides coverage for a limited range of medically necessary goods and services, including prescription drugs.[165] To protect clients from the risks associated with prescription drug abuse, as well as respond to potential misuses of these drugs, NIHB introduced a prescription monitoring program, which is used to prevent double-doctoring, as well as to monitor clients who are on high doses of one or more drugs of concern, including opioids, stimulants or benzodiazepines. The prescription drug monitoring program sends warning and rejection messages to pharmacies to alert them of situations of potential misuse. Meanwhile, NIHB has also introduced coverage restrictions on drugs that could be abused, including limiting the amount of the drug that a client can receive per day. In addition, NIHB uses surveillance information from the prescription monitoring system to address the prescribing practices of health care practitioners by finding out the reasons for the high dosage levels of these prescription drugs; promoting the tapering of dosages; and encouraging physicians to prescribe alternative non-opioid medications as appropriate. Taken together, the Committee heard that there had been a 36% reduction in the number of benzodiazepine clients and 7.5% decrease in the number of high-dose opioid clients since 2012.[166]

In its appearance before the Committee, the National Native Addictions Partnership Foundation (NNAPF) explained that other initiatives have been developed to address prescription drug abuse in First Nations communities.[167] In particular, Honouring Our Strengths: A Renewed Framework to Address Substance Abuse Issues Among First Nations Peoples of Canada was developed in partnership with the Assembly of First Nations (AFN) and Health Canada to guide the provision of substance abuse programs and services in First Nations communities in a manner that is both culturally relevant and client-focused.[168] It addresses strengthening the system of care, improving the quality of programming, enhancing measurement and oversight, and improving coordination and integration at all levels of government. According to NNAPF, current efforts to implement the framework supports a comprehensive response to prescription drug abuse issues for First Nations people.

Both the AFN and NNAPF explained that they are also working with Health Canada to develop a First Nations Mental Wellness Continuum Framework, which describes a vision for First Nations’ mental wellness that centres on culture, including First Nations values, knowledge, languages and practices.[169] The Framework has five themes: culture, community development and ownership, quality health care systems, collaboration, and enhanced flexible funding arrangements. The Committee heard that these two organizations are also involved in the development of other strategies that will help address prescription drug abuse, including the First Do No Harm: Responding to Canada’s Prescription Drug Crisis and the federal government’s National Anti-Drug strategy.[170]

These witnesses also highlighted concrete specific community initiatives that had been effective in addressing prescription drug abuse in First Nations communities. For example, the Committee heard that First Nations communities have invested in culturally-based opioid replacement therapy programs.[171] In particular, the communities invested in the provision of Suboxone for opioid replacement therapy because it is easier to store and dispense in Northern and remote communities than is methadone. A representative of the NNAPF explained that Suboxone therapy is integrated into holistic treatment programs that include counselling with cultural practitioners, culturally relevant community development initiatives and life skills development.

The NNAPF representative also described a school-based early intervention program that trains First Nations addictions counsellors and school personnel to work with youth in grades 7 and 8 in First Nations communities to address prescription drug abuse.[172] The Committee heard that over 40 communities are now using this program, which has been well received and matches the provincial education standards related to health.

According to both the NNAPF and the AFN, successful initiatives aimed at addressing prescription drug abuse in First Nations communities are ones that are culturally based and informed by an understanding of the history of colonialism and its effects on First Nations people. Many members of First Nations are unaware of the colonial history that has shaped their communities, including the legacies of the Indian Act, the Residential School System, and the “Sixties Scoop”. As a result, many individuals are unaware of the associated experiences of physical, emotional, and sexual abuse, and loss of family and culture that have given rise to many of the challenges that they face. Consequently, many have internalized the problems in their communities and their families, as a reflection of themselves and their race, rather than as a product of colonization. The Committee heard that culturally based programs replace these negative self-images of First Nations people with positive ones that focus on the strengths of their culture and indigenous knowledge and practices. The representative from NNAPF explained that 86% of individuals who attended a youth treatment centre that had adopted culturally based treatment maintained their wellness in the post-treatment period, in comparison to 50% completion rates for other youth treatment centres.

These witnesses also outlined ways that further progress could be made in addressing prescription drug abuse in First Nations communities. Primarily, the Committee heard that there is a need to increase access through the NIHB program to opioid substitution therapy, in particular Suboxone, which can be administered by nurses in Northern and remote communities.[173] According to one witness, outside Ontario, NIHB provides coverage for Suboxone only when it is prescribed by a physician who is licensed to prescribe methadone.[174] In addition, the AFN recommended that NIHB remove the generic version of oxycodone from its formulary in favour of tamper-resistant formulations.[175] A representative of the AFN also explained that there is a need for a broader review of the NIHB to ensure that it is meeting the needs of First Nations and Inuit communities, noting these conversations are currently underway with Health Canada.[176] However, the organization recommended that this Committee also undertake a comprehensive review of the program.[177]

Furthermore, the Committee heard that additional resources are necessary for the NNADAP and the NYSAP to provide community-based resources to address prescription drug abuse.[178] The representative from NNAPF also recommended that Health Canada and Aboriginal Affairs and Northern Development Canada work together more closely to coordinate their programs geared towards mental wellness.[179] Witnesses stressed that programs and initiatives must be community-designed, as each community has different needs.

The Committee also received a written submission from Inuit Tapiriit Kanatami (ITK) that noted that though prescription drug abuse is a growing public and health concern within Inuit communities, little data and information are available to identify and monitor the problem.[180] In addition, ITK wrote that it applauds the Canadian Centre on Substance Abuse’s creation of the pan-Canadian strategy First Do No Harm: Responding to Canada’s Prescription Drug Crisis. However, the organization noted that it did not participate in the development of this strategy. Consequently, the organization recommended that Health Canada work with ITK and the Canadian Centre on Substance Abuse to collect Inuit-specific data to inform an Inuit-specific approach to the issues surrounding prescription drug abuse. It also indicated that an Inuit-specific approach to this issue requires a coordinated approach among Inuit Nunangat, territories, provinces and land claim organizations.

COMMITTEE OBSERVATIONS AND RECOMMENDATIONS

The problem of prescription drug misuse is complex. There is no simple solution. The answer lies in a nationally coordinated, multi-pronged approach. This is a difficult task that will become more difficult the longer we delay. The evidence is in, the analyses are done, and the pathway has been charted. What is needed now is a unified political and professional will to move forward and to keep the resolution of this public safety crisis as a priority.[181]

Dr. Roger Skinner¸ Regional Supervising Coroner, Office of the Chief Coroner of Ontario

As reflected in the words of Dr. Skinner in his testimony before the Committee, prescription drug abuse is a growing concern among Canadians and a challenging problem to address. However, during the course of the study, witnesses also described the efforts already underway to address this problem. At the federal level, the Committee heard that the government committed in the 2013 Speech from the Throne to expand the National Anti-Drug Strategy to address prescription drug abuse.[182] The Committee notes that Budget 2014 expands upon this commitment by providing $44.9 million over five years to support new actions, including: educating Canadian consumers on the safe use, storage and disposal of prescription medications; enhancing prevention and treatment services in First Nations communities; increasing inspections to minimize the diversion of prescription drugs from pharmacies for illegal sale; and improving surveillance data on prescription drug abuse in Canada.[183] The Committee also notes that the President of Purdue Pharma Canada agreed that he would take back a request to his company from a Committee member to have the company match the funds provided in the Budget 2014, which would be invested in treatment programs for those addicted to opioids.[184] Witnesses appearing before the Committee spoke in favour of the federal government expanding the National Anti-Drug Strategy to include prescription drug abuse, and indicated their support for the specific measures that were outlined in Budget 2014. Furthermore, witnesses presented additional ways that the federal government could play a role in addressing prescription drug abuse in Canada both within the context of the National Anti-Drug Strategy and in the development of a pan-Canadian strategy to address this issue, and through its role as a regulator of the pharmaceutical supply chain. It is within this context that the Committee presents its observations and recommendations, which highlight ways that the federal government can continue to move forward in addressing this complex issue.

A. Regulation of the Pharmaceutical Supply Chain

Witnesses identified how the federal government could address prescription drug abuse in its role as a regulator of prescription drugs under the Food and Drugs Act. For example, the Committee heard that Health Canada could help to prevent prescription drug abuse by approving only brand-name or generic prescription drugs with addiction potential that have tamper-resistant formulations. Witnesses also said that Health Canada officials need to take into consideration evidence regarding the broader health- and social-related harms of a prescription drug in the approval of its generic equivalent, rather than examining only evidence related to the risks in the drug’s intended population. Finally, witnesses suggested that Health Canada needs to review the labels, product monographs and advertising of prescription drugs, including opioids, stimulants, sedatives and tranquilizers, to determine whether they accurately reflect the risks and addiction potential of these medications.

The Committee also heard that, in order to strengthen its regulation of prescription drugs that contain substances controlled under the Controlled Drugs and Substances Act, the federal government needs to review this legislation to ensure that it reflects the current reality of health care delivery. Furthermore, witnesses recommended that Section 56 of the Act be examined, in consultation with stakeholders, to determine whether it should include additional requirements for prescribers of these substances, such as additional training, or licensing, to support the appropriate prescribing of these drugs. In addition, witnesses felt that this section of the Act also needs to be reviewed to determine whether it creates unnecessary barriers to the treatment of addictions through its licensing requirements for methadone used in opioid substitution therapy. Witnesses also recommended that national standards be developed for the disposal of prescription drugs regulated in the Act. While witnesses also pointed to the need for increased inspection and monitoring to ensure compliance with the Act, the Committee notes that the federal government has already committed to increased funding in this area as part of the expansion of the National Anti-Drug Strategy in Budget 2014. The Committee therefore recommends that:

RECOMMENDATION 1

Health Canada consider the merits of tamper-resistant formulations in addressing prescription drug abuse.

RECOMMENDATION 2

Health Canada consider amending its regulatory and policy framework for the approval of prescription drugs to allow for the inclusion of evidence related to the risks of the drug in populations for which it is not intended.

RECOMMENDATION 3

Health Canada take into consideration decisions made in other jurisdictions related to the approval of prescription drugs, whether generic or brand-name equivalents, with addiction potential.

RECOMMENDATION 4

Health Canada take action with regard to drug labels for prescription drugs with addiction potential so that they more accurately reflect risks and safety concerns.

RECOMMENDATION 5

Health Canada review, in cooperation with stakeholders, inappropriate marketing practices that have an effect on prescribing practices.

RECOMMENDATION 6

Health Canada consider undertaking a review of the Controlled Drugs and Substances Act, in consultation with stakeholders, to determine whether the Act needs to be modernized to enhance the ability of governments, health care providers and law enforcement to respond more effectively to prescription drug abuse in Canada.

RECOMMENDATION 7

Health Canada, in collaboration with stakeholders, develop national guidelines for the safe disposal of prescription drugs that contain substances regulated under the Controlled Drugs and Substances Act.

B. Support for a Pan-Canadian Strategy to Address Prescription Drug Abuse

In addition, the Committee heard that there is a need for a pan-Canadian strategy to mobilize all levels of government and stakeholders to take action to address prescription drug abuse in Canada. Such a strategy, entitled First Do No Harm: Responding to Canada’s Prescription Drug Crisis, has already been developed by the Canadian Centre on Substance Abuse and 20 other partners. Many witnesses appearing before the Committee endorsed this strategy, recommending that the federal government provide resources to promote the strategy’s implementation. The Committee therefore recommends that:

RECOMMENDATION 8

The federal government continue to implement its National Anti-Drug Strategy with consideration to the Canadian Centre on Substance Abuse`s pan-Canadian strategy entitled First Do No Harm: Responding to Canada’s Prescription Drug Crisis.

C. Best Practices for Prevention and Raising Awareness

Witnesses also identified ways in which the federal government could help to prevent prescription drug abuse and raise awareness of the issue. In line with commitments made in Budget 2014, witnesses recommended that the federal government raise public awareness about prescription drug abuse, which could include marketing campaigns targeted towards different audiences, including prescribers, patients, seniors, Aboriginal peoples and the general population, as well as continue to support measures such as the National Prescription Drop-off Day.

To help prevent prescription drug abuse, witnesses also recommended that the federal government support the development and implementation of tools to promote appropriate prescribing practices among health care professionals, such as evidence-based clinical practice guidelines for the prescribing of opiates, benzodiazepines and stimulants. Witnesses also stressed the importance of raising awareness about opioid overdoses, as well as providing support for community-based take-home naloxone programs, which have been shown to reduce the incidence of opioid-related overdoses. The Committee heard that the federal government could facilitate the provision of naloxone by removing the requirement for a prescription for this drug under Schedule F of the Food and Drugs Act, as well as working with pharmaceutical companies to reduce its costs. In addition, one witness recommended that the federal government amend the Controlled Drugs and Substances Act to provide protection from arrest and prosecution for drug crimes for individuals who call 911 for help in a drug overdose event, as well as the development of a monitoring system that would track overdoses. The Committee therefore recommends that:

RECOMMENDATION 9

Health Canada work with stakeholders to share the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Cancer Pain with regulatory bodies as a possible best practice to evaluate the prescribing practices of health care practitioners.

RECOMMENDATION 10

The federal government endeavour to share best practices across jurisdictions on the prescribing of drugs with addiction potential.

RECOMMENDATION 11

The federal government develop public awareness campaigns aimed at preventing prescription drug abuse.

RECOMMENDATION 12

Health Canada examine the risks and benefits of naloxone in addressing prescription drug abuse and consider amending the Controlled Drugs and Substances Act to allow for Good Samaritan legislation, as utilized in the United States.

D. Monitoring and Surveillance

The Committee heard that there is a need for a pan-Canadian, interoperable, prescription drug monitoring system to identify the scope of the prescription drug abuse, promote appropriate prescribing, and prevent diversion of prescription drugs from the pharmaceutical supply chain. The Committee notes that funding has been provided through the National Anti-Drug Strategy for the development of surveillance data in this area. Witnesses appearing before the Committee also highlighted specific actions that the federal government could take in the area of monitoring and surveillance, including evaluating existing prescription drug monitoring systems in different jurisdictions to identify best practices, as well as developing national standards for data collection to monitor prescription drug abuse. The Committee therefore recommends that:

RECOMMENDATION 13

Health Canada work with provinces and territories to evaluate existing prescription drug monitoring systems across Canada and in other countries to identify best practices in this area.

RECOMMENDATION 14

Health Canada and the Canadian Institute for Health Information work with stakeholders to identify national standards for data collection for prescription drug monitoring systems across the country.

RECOMMENDATION 15

Health Canada work with stakeholders, provinces and territories to identify best practices in the monitoring of adverse drug reactions and drug overdoses.

E. Prevention and Treatment of Prescription Drug Abuse in First Nations and Inuit Communities

According to Budget 2014, funding will be allocated through the National Anti-Drug Strategy to support the prevention and treatment of prescription drug abuse in First Nations and Inuit communities. Witnesses recommended that this funding be targeted towards the provision of community-based prevention and treatment services that are culturally based, which would include increased access to Suboxone, an opioid replacement therapy. Finally, the Committee heard that Inuit should also be included in the development of strategies aimed at addressing prescription drug abuse in their communities. The Committee therefore recommends that:

RECOMMENDATION 16

Health Canada continue to direct funding in the National Anti-Drug Strategy to support the provision of community-based prevention and treatment services that are culturally based.

RECOMMENDATION 17

Health Canada work with provinces and territories to assess multi-disciplinary and alternative pain management programs in rural and remote areas to ensure that they have access to comprehensive pain management systems.

RECOMMENDATION 18

Health Canada work with territorial governments and Inuit Tapiriit Kanatami and the Canadian Centre on Substance Abuse to collect Inuit-specific data to inform an Inuit-specific approach to the issues surrounding prescription drug abuse.

F. Combatting the Stigma of Addiction

Witnesses stressed the importance of addressing the stigma that people with addictions face in order to promote treatment and recovery. The Committee heard that this could be achieved through a national public awareness campaign developed in collaboration with addiction experts and individuals in recovery from addiction, and support for initiatives such as National Recovery Day, which celebrates individuals in recovery and their families. The Committee therefore recommends that:

RECOMMENDATION 19

Health Canada, in collaboration with addiction experts and individuals in recovery from addiction, work to address the stigma associated with addiction.

RECOMMENDATION 20

The federal government target funds through the National Anti-Drug Strategy to establish an awareness campaign focusing on the risks associated with prescription drug abuse and how to properly and security store, monitor and dispose of prescription drugs.