First Do No Harm: Responding to Canada s Prescription Drug Crisis

Transcription

1 First Do No Harm: Rsponding to Canada s Prscription Drug Crisis Annual Rport On bhalf of th First Do No Harm National Advisory Council

2 First Do No Harm: Rsponding to Canada s Prscription Drug Crisis: Annual Rport This documnt was publishd by th Canadian Cntr on Substanc Abus (CCSA). Suggstd citation: Canadian Cntr on Substanc Abus. (2014). First do no harm: Rsponding to Canada s prscription drug crisis: annual rport, Ottawa, ON: Author. Canadian Cntr on Substanc Abus, CCSA, Albrt Strt Ottawa, ON K1P 5E7 Tl.: pharma@ccsa.ca Production of this documnt has bn mad possibl through a financial contribution from Halth Canada and a grant from Albrta Halth. Th viws xprssd hrin do not ncssarily rprsnt th viws of Halth Canada or Albrta Halth. This documnt can also b downloadd as a PDF at C documnt st égalmnt disponibl n français sous l titr : S abstnir d fair du mal : Répondr à la cris lié aux médicamnts d ordonnanc au Canada Rapport annul, ISBN

3 Tabl of Contnts Excutiv Summary... 1 Th Stratgy... 1 National Initiativs... 1 Activitis of th Implmntation Tams... 2 Th Way Forward... 3 Introduction... 4 Focus of th Stratgy... 4 Th Rcommndations... 5 Brathing Lif Into th Rcommndations... 6 FDNH on th National Stag... 7 Th 2013 Spch from th Thron... 7 Funding to Support Expandd National Anti-Drug Stratgy... 7 Fdral/Provincial/Trritorial Working Group on Prscription Drug Abus... 7 Hous of Commons Standing Committ on Halth... 8 Ministrs Symposium on Prscription Drug Misus... 8 Snat Committ Examining Prscription Pharmacuticals in Canada... 9 Othr National Initiativs Provincial/Trritorial Initiativs Priority Rcommndations and Tam Activitis Prvntion Tam Education Tratmnt Monitoring and Survillanc Enforcmnt Lgislation and Rgulation... 19

4 A National Priority Th Way Forward Challngs Opportunitis Gt Involvd Rfrncs Appndix A Appndix B Appndix C... 31

5 Excutiv Summary Th Stratgy First Do No Harm: Rsponding to Canada s Prscription Drug Crisis (th Stratgy) is a 10-yar roadmap to rduc th harms associatd with prscription drugs whil giving important considration to thir thraputic uss. Undr th ladrship of th Canadian Cntr on Substanc Abus (CCSA), th Coalition on Prscription Drug Misus (Albrta) and th Nova Scotia Dpartmnt of Halth and Wllnss, in partnrship with Halth Canada s First Nations and Inuit Halth Branch s Prscription Drug Abus Coordinating Committ, th Stratgy was dvlopd by th National Advisory Council on Prscription Drug Misus a divrs group of individuals rprsnting govrnmnts, halth profssionals (including coronrs, dntists, nurss, pharmacists and physicians), patints and familis, First Nations, nforcmnt officials, rgulators, industry ladrs and rsarchrs. Th Stratgy prsnts 58 achivabl short- and longr-trm rcommndations around fiv strams of action: Prvntion, Education, Tratmnt, Monitoring and Survillanc, and Enforcmnt, and thr aras of focus that cut across all strams: Lgislation and Rgulation, Rsarch and Evaluation and Prformanc Masurmnt. Th Stratgy was rlasd in March 2013 and during th first yar, six implmntation tams wr formd, on for ach stram of action, and on for Lgislation and Rgulation, to brath lif into th rcommndations. Ovr 50 individuals wr rcruitd, many of thm ladrs in thir fild, rprsnting a similar numbr of organizations and broadr ntworks from across th country, to commit to on or mor of th implmntation tams and to th First Do No Harm National Advisory Council (NAC) that now guids th implmntation of th Stratgy. Th rsult of this commitmnt is rflctd in th substantial progrss that has bn mad in th first yar sinc th Stratgy was launchd. National Initiativs Mmbrs of NAC and th implmntation tams wr ngagd on th national and provincial stag in activitis that align with th rcommndations of th Stratgy such as: Participation on th Fdral, Provincial and Trritorial Working Group on Prscription Drug Abus; Prsntations to Hous of Commons Standing Committ on Halth s study of th rol of th fdral govrnmnt in addrssing prscription drug abus; Ladrship of, and participation in, th Symposium on Prscription Drug Abus co-hostd by CCSA s CEO, Michl Prron, and th Honourabl Rona Ambros, Ministr of Halth; Prsntations to th Snat Committ xamining prscription pharmacuticals in Canada; Participation in a numbr of initiativs at th provincial and trritorial lvl that align with th rcommndations containd within th Stratgy, including rsarch on British Columbia s Tak- Hom Naloxon pilot program, changs to Albrta s buprnorphin/naloxon prscribing rgulations and Ontario s cration of a ral-tim survillanc systm to track ovrdos daths and injuris in hospital mrgncy rooms; and Advocating for th support of prscription drug-rlatd initiativs announcd during th 2013 Spch from th Thron. Pag 1

6 Activitis of th Implmntation Tams Th First Do No Harm Excutiv Council (rprsnting co-lads from ach of th implmntation tams and th co-chairs of th First Do No Harm National Advisory Council) mt through th yar to guid th implmntation of th Stratgy and shar thir activitis within thir organizations to lvrag th fforts of ach mmbr organization. In addition, th majority of th implmntation tams committd to monthly tlconfrnc mtings to plan and xcut projcts in alignmnt with th rcommndations. Highlights of ths projcts includd: Supporting th Institut for Saf Mdication Practics in dvloping patint ducation matrials on th saf us of opioid mdications; Complting an nvironmntal scan of xisting social markting campaigns rlatd to prscription drugs, including vidnc of thir ffctivnss to inform futur social markting initiativs; Conducting a rviw of profssional and fdral guidlins on th saf disposal of prscription mdication; Participating, as co-invstigators and knowldg usr partnrs in th Scond Chancs study of th ffctivnss of British Columbia s Tak-Hom Naloxon program; Dvloping comptncis rquird to addrss harms of prscription drug us for a rang of halthcar practitionrs who work with patints facing addictions, mntal halth, co-morbiditis, concurrnt disordrs and pain issus; Complting an nvironmntal scan of xisting continuing ducation offrings for both prscribing and dispnsing halthcar profssionals to idntify gaps and opportunitis for improvmnt; Conducting a survy of physicians, pharmacists, dntists and nurss practicing within th provinc of Albrta to bttr undrstand halthcar profssionals prcptions of illicit drug us and local stratgis for action with a viw to informing ducational curricula; Contributing to a Canadian Instituts of Halth Rsarch (CIHR) grant application to conduct a systmatic rviw of xisting stratgis, framworks, collaborativ ntworks and matrials to promot th appropriat us and rduc abus of prscription opioids, and idntify gaps, inconsistncis and duplication among stratgis to guid futur rsarch and practics; Scuring funding for mtings of stakholdrs to bgin standardizing th lmnts of a national prscription drug survillanc systm and a prscription monitoring program (PMP) community of practic; Complting a litratur rviw on th cor componnts of ffctiv PMPs; Complting a study to dtrmin th cost-impact of prscription drugs on th Canadian criminal justic systm, including law nforcmnt, proscution srvics and corrctional srvics; Hosting th first annual National Prscription Drug Drop-off Day, which rsultd in th rturn of ovr 900 kilograms of drugs that ar now no longr availabl for divrsion, and planning for th nxt vnt in 2014; Writing lttrs to Halth Canada to addrss aras for improvmnt in lablling and product monographs and to provid rcommndations for changs to th Controlld Drugs and Substancs Act and th r-scoping of th National Anti-Drug Stratgy (NADS) to includ prscription drugs; Pag Pag2 2

7 Rviwing fdral rgulatory rquirmnts with a viw to idntifying aras whr rgulations could b strngthnd; Th Way Forward With so many activitis undrway across th country, th momntum bhind th First Do No Harm Stratgy is building; howvr, funding for th Stratgy s implmntation has bn vry limitd. Dspit th shortag in rsourcs, th tams hav managd to mov forward and hav prioritizd activitis to b addrss in th coming yar; howvr, to do so rquirs contingnt ngagmnt of all mmbrs and mmbr organizations and on funding to support th significant work that lis ahad. Through th availability of appropriat rsourcs, CCSA can ffctivly continu in its ladrship rol, as rqustd by NAC, to s th Stratgy through to its full implmntation. This work includs providing th backbon support and guidanc rquird to implmnt th ndd action, shar information, build upon th initiativs that ar undrway, and lvrag th momntum that has bn cratd to achiv a gratr collctiv impact. To gt involvd, contact pharma@ccsa.ca. Pag Pag3 3

8 Introduction First Do No Harm: Rsponding to Canada s Prscription Drug Crisis (th Stratgy) is a 10-yar roadmap to rduc th harms associatd with prscription drugs whil giving important considration to thir thraputic uss. Th Canadian Cntr on Substanc Abus (CCSA), th Coalition on Prscription Drug Misus (Albrta) and th Nova Scotia Dpartmnt of Halth and Wllnss ld th dvlopmnt of th Stratgy, in partnrship with Halth Canada s First Nations and Inuit Halth Branch s Prscription Drug Abus Coordinating Committ. Th Stratgy, initiatd in rspons to a growing nation-wid concrn about harms associatd with prscription drug us in Canada, was dvlopd by th National Advisory Council on Prscription Drug Misus a divrs group of individuals rprsnting govrnmnts, halth profssionals (including coronrs, dntists, nurss, pharmacists and physicians), patints and familis, First Nations, nforcmnt officials, rgulators, industry ladrs, and rsarchrs. Focus of th Stratgy Th Stratgy addrsss prscription drugs that hav lgal status and thraputic uss, togthr with a high potntial for harm. Ths mdications includ: Opioid pain rlivrs such as thos containing oxycodon, hydromorphon, fntanyl, morphin and codin; Stimulants such as thos containing dxtroamphtamin, mthylphnidat and amphtamins; Sdativ-hypnotics such as thos containing bnzodiazpins such as diazpam and alprazolam; and Thos mdications usd to trat addiction and pain, but that can also rsult in harm, such as mthadon and buprnorphin. Th Stratgy focuss on th harms associatd with ths prscription drugs and rcognizs that th harms nd to b considrd along with th bnfits th drugs can dlivr. Th harms includ addiction, illnss rquiring hospitalization, ovrdos and dath associatd with problmatic us, ovr-consumption, poly-drug us and non-mdical us, as wll as with thraputic us, whn mdications ar not takn as prscribd. Th associatd impacts and costs physical, motional, psychological and public safty ar born by individuals, familis, communitis and socity at larg. Effctiv tratmnt and prvntion approachs nd to attnd to th divrsity of populations, including thir gographical and cultural contxts, and many othr factors that contribut to risk and th impacts of ths prscription drugs across th systm. To rduc ths harms, th Stratgy also addrsss: Divrsion away from th authorizd supply chain from manufacturr to patint; Inappropriat prscribing and dispnsing bhaviour; and Addiction, mntal halth, co-morbiditis, concurrnt disordrs and pain, all of which ar affctd by ths prscription drugs. Pag Pag4 4

9 Th Rcommndations Through a commitmnt to coordinatd action across its multi-sctorial mmbrship, th National Advisory Council workd intnsivly for 14 months to dvlop th Stratgy. Th final product outlins 58 consnsus rcommndations in fiv strams of action: Prvntion, Education, Tratmnt, Monitoring and Survillanc, and Enforcmnt; and thr aras of focus that cut across all strams: Lgislation and Rgulation, Rsarch, and Evaluation and Prformanc Masurmnt. A full dscription of ths rcommndations is availabl in th Stratgy documnt, First Do No Harm: Rsponding to Canada s Prscription Drug Crisis rlasd in March Th prsnt rport summarizs th progrss that has bn mad in th first yar sinc th landmark First Do No Harm Stratgy was rlasd. Pag Pag5 5

10 Brathing Lif into th Rcommndations Building on th momntum cratd through th dvlopmnt of th Stratgy, many of th mmbrs of th National Advisory Council on Prscription Drug Misus agrd to co-lad implmntation tams to brath lif into th rcommndations laid out by th Stratgy. Six implmntation tams (hraftr rfrrd to as Tams) wr assmbld, on for ach stram of action, as wll as on for th Lgislation and Rgulations ara of focus. CCSA idntifid additional co-lads, as rquird, to provid dirction to th work of ach Tam. Th first stp for th co-lads was to rcruit subjct mattr xprts, som of whom wr alrady involvd in th Stratgy s dvlopmnt, as wll as nw mmbrs who joind th Stratgy sinc its launch in March 2013, to commit to taking action on th rcommndations. To dat, ovr 50 individuals, many of thm ladrs in thir fild, rprsnting a similar numbr of organizations and broadr ntworks from across th country hav mad a commitmnt to on or mor of th Tams and to th First Do No Harm National Advisory Council (NAC) that now guids th implmntation of th Stratgy (s Appndix A for th NAC govrnanc structur). Th Tams ar rsponsibl for th implmntation of th Stratgy s 58 rcommndations. Tam activitis involv mting rgularly, monitoring progrss, assssing rsourc nds, stting annual prioritis, dvloping plans of action with concrt dlivrabls and rcruiting nw mmbrs as ndd to achiv milstons towards fulfillmnt of th rcommndations. Th Excutiv Council, composd of th tam co-lads and NAC co-chairs, also mt by tlconfrnc to shar information, idntify aras for potntial collaboration, coordinat Stratgy implmntation and communicat on bhalf of th Stratgy. In March 2014, th NAC mt fac-to-fac to clbrat th yar s accomplishmnts, idntify opportunitis for cross-tam collaboration and solidify ach Tam s work plans for th yar ahad. Th mting includd rprsntativs from Halth Canada who rportd on fdral activitis rlatd to prscription drug abus and listnd to updats from ach of th Tams on th work compltd ovr th prvious yar and th opportunitis and challngs facing thm as thy look ahad. Th mting was a rmindr of th valu of fac-to-fac tim in crating momntum and inspiring th voluntary group working to implmnt th Stratgy. Dspit working with limitd rsourcs, th Tams hav rmaind committd to th Stratgy s implmntation and hav bn abl to prioritiz and tak action toward th fulfillmnt of many of th Stratgy s rcommndations. All th whil, CCSA has continud to provid backbon scrtariat and othr support, hlping tams with rcruitmnt, idntifying prioritis and timlins for taking action, xploring funding options, and supporting rsarch initiativs. Many of th activitis of th first yar involvd conducting th foundational prliminary work rquird for th full ralization of th rcommndations. Ths activitis rprsnt arly days in what is a 10- yar initiativ. Th following sctions of this rport summariz national activitis in which NAC mmbrs hav bn involvd, as wll as th priority rcommndations and corrsponding accomplishmnts of ach of th implmntation tams. Pag Pag6 6

11 Th First Do No Harm Stratgy on th National Stag A numbr of activitis of a national scop hav takn plac ovr th past yar that complmnt th Stratgy and ar hlping to mov th rcommndations forward. CCSA and many mmbrs of NAC hav participatd dirctly in th majority of th following national initiativs. Th 2013 Spch from th Thron Th 2013 Spch from th Thron includd svral commitmnts rlatd to th First Do No Harm Stratgy: a) to xpand Canada s National Anti-Drug Stratgy to addrss th growing problm of prscription drug abus; b) to nsur that drug labls ar writtn in plain languag and that th potntial sid ffcts of mdication ar accuratly indicatd; and c) to introduc nw patint safty lgislation to hlp idntify potntially dangrous drugs and nsur th quick rcall of unsaf drugs. Th xpansion of th National Anti-Drug Stratgy to includ prscription drug abus was wlcom nws to CCSA and th First Do No Harm NAC and implmntation tams. Th announcmnt was rcivd as Halth Canada s rcognition of th importanc of taking action to addrss th issu at a national lvl, as articulatd in th First Do No Harm Stratgy for Canada. Funding to Support Expandd National Anti-Drug Stratgy Th 2014 fdral budgt includd $44.9 million dollars ovr fiv yars to support xpanding th focus of th National Anti-Drug Stratgy to includ prscription drugs. Th mony will b dirctd towards initiativs such as ducating Canadian consumrs on th saf us, storag and disposal of prscription drugs and nhancing th tratmnt and prvntion of prscription drug abus in First Nations communitis. Proposals submittd to th Halth Canada s Drug Tratmnt Fund Program can now includ prscription drug abus within thir scop. Thos involvd in th First Do No Harm Stratgy hop to scur som of this funding to support th implmntation of th Stratgy. Fdral/Provincial/Trritorial Working Group on Prscription Drug Abus Th Fdral/Provincial/Trritorial (FPT) Working Group on Prscription Drug Abus is mad up of rprsntativs from provincial and trritorial halth ministris and Halth Canada. Th group, cochaird by Carolyn Davison, from th Nova Scotia Dpartmnt of Halth and Wllnss, and Michll Kovacvik, from Halth Canada, was formd to addrss concrns about harms associatd with prscription drug us. In addition to Carolyn Davison, othr mmbrs of NAC ar also part of th working group, which has hlpd to nsur a coordinatd ffort by th working group and th First Do No Harm implmntation tams. During thir most rcnt mting, th group agrd to targt a numbr of short-trm activitis that includ initiating th dvlopmnt of a national survillanc plan, stablishing a prscription monitoring program (PMP) ntwork, and coordinating activitis to ducat halth practitionr, including dntists, nurss, pharmacists and physicians. Pag Pag7 7

12 Dr. Bth Sproul, Lad of th Monitoring and Survillanc Tam, has bn invitd to work with th FPT Working Group toward stablishing a national survillanc systm and ntwork of PMPs. In addition, Nova Scotia has providd funding to host a mting in May 2014 of th Monitoring and Survillanc Tam, th FPT rprsntativs of prscription monitoring programs and othr ky stakholdrs to discuss and initiat a consnsus procss to standardiz th ky lmnts of a national survillanc systm, spcifically data strams, dfinitions and common trminology, and cor indicators. Th mting will also srv to initiat th dvlopmnt of a Canadian prscription monitoring program community of practic, including th framwork, objctivs, cor componnts and prioritis. Hous of Commons Standing Committ on Halth In Novmbr 2013, th Hous of Commons Standing Committ on Halth bgan a study of th fdral govrnmnt s rol in addrssing prscription drug abus in Canada. Th committ was chaird by Bn Lobb, M.P. for th Ontario riding of Huron-Bruc. Th study focusd on th following thr aras: Th currnt scop of th problm, including what populations ar most at-risk; Bst practics for prvntion and raising awarnss of th problm; and Promising stratgis to addrss this issu at th community lvl. A sris of mtings wr hld through to Fbruary 2014 during which 17 mmbrs of First Do No Harm implmntation tams plus additional mmbr organizations, as wll as CCSA CEO, Michl Prron, prsntd witnss statmnts to th committ. Many rfrncd th First Do No Harm Stratgy in thir tstimony. Th final rport on th fdral govrnmnt s rol in addrssing prscription drug abus in Canada was rlasd on April 10, 2014, and listd 20 rcommndations, most of which align closly with thos found in th rfrnc to th First Do No Harm Stratgy. Ths rcommndations includ: Rcommndation 5: Halth Canada rviw, in coopration with stakholdrs, inappropriat markting practics that hav an ffct on prscribing practics; Rcommndation 8: Th fdral govrnmnt continu to implmnt its National Anti-Drug Stratgy with considration to th CCSA s pan-canadian stratgy ntitld First Do No Harm: Rsponding to Canada s Prscription Drug Crisis; Rcommndation 10: Th fdral govrnmnt ndavour to shar bst practics across jurisdictions on th prscribing of drugs with addiction potntial; Rcommndation 18: Halth Canada work with trritorial govrnmnts and Inuit Tapiriit Kanatami and th CCSA to collct Inuit-spcific data to inform an Inuit-spcific approach to th issus surrounding prscription drug abus; and Rcommndation 20: Th fdral govrnmnt targt funds through th National Anti-Drug Stratgy to stablish an awarnss campaign focusing on th risks associatd with prscription drug abus and how to proprly and scurity stor, monitor and dispos of prscription drugs. Ministrs Symposium on Prscription Drug Misus On January 24, 2014, th Honourabl Rona Ambros, Ministr of Halth, and Michl Prron, CEO, CCSA co-hostd th Symposium on Prscription Drug Abus in Toronto, Ontario. Th invitd attnds rprsntd a rang of disciplins and organizations, many of which wr mmbrs of NAC. Attnds includd xprts in th fild of addiction and pain tratmnt, and rprsntativs of halth profssional Pag Pag8 8

13 rgulatory authoritis and profssional associations (including dntists, nurss, pharmacists and physicians), law nforcmnt, acadmic institutions, patint safty organizations, First Nations, govrnmnt, and th pharmacutical industry. Also in attndanc wr Gorg Da Pont, Dputy Ministr of Halth, and Bn Lobb, M.P., Chair for th Hous of Commons Standing Committ on Halth Th vnt addrssd prscription drug abus in th contxt of th thr major thms of th National Anti-drug Stratgy, Prvntion, Tratmnt and Enforcmnt, along with a brakout sssion on Prscribr Practics and Education ld by Dr. Louis Francscutti, Prsidnt, Canadian Mdical Association, and Dr. Kathy Lawrnc, Prsidnt, Collg of Family Physicians. Ovr th cours of th day, fiv common thms or suggstions wr mphasizd across th four sssions: PMPs in vry provinc and trritory that allow information sharing across prscribrs, dispnsrs and nforcmnt agncis to support th monitoring of prscription and disbursmnt of prscription drugs to idntify high-risk patints and high-risk prscribing bhaviour. A national survillanc systm to track pattrns of prscription drug misus and harms at national, provincial and trritorial lvls to valuat th impact of intrvntions and provid vidnc to inform ongoing policy and practic. Th systm would includ data from provincial/trritorial and national (Non-Insurd Halth Bnfits) PMPs, as wll as hospital admissions, mrgncy room visits, coronr s data, poison control cntrs, vtrinarians and nforcmnt. Improvd prscribr ducation to nsur appropriat us of prscription mdications and nonpunitiv approachs to continuing ducation. Improvd accss to a rang of addiction and pain tratmnt srvics, including th physical and conomic availability of non-pharmacological and traditional tratmnt options. Rcognition of th collctiv ffort that will continu to b rquird to addrss th highly complx issu of prscription drug abus and to lvrag th work that has alrady bn initiatd, including th National Anti-Drug Stratgy and th First Do No Harm Stratgy. Ths thms ar consistnt with rcommndations of th First Do No Harm Stratgy and rinforc that th Stratgy continus to rflct th concrns of th nation s ladrs and xprts daling with th issu of th harms associatd with th us of prscription drugs. Th vnt providd CCSA and NAC mmbrs with th opportunity to dvlop nw rlationships with partnrs intrstd in bcoming involvd in th Stratgy. CCSA and NAC hav wlcomd th involvmnt of th Canadian Mdical Association in th implmntation of th Stratgy and look forward to collaborating with this organization. Snat Committ Examining Prscription Pharmacuticals in Canada In Novmbr 2013, th Standing Snat Committ on Social Affairs, Scinc and Tchnology was authorizd by th Snat to xamin and rport on four main aspcts of prscription pharmacuticals in Canada including: Th procss to approv prscription pharmacuticals with a particular focus on clinical trials; Th post-approval monitoring of prscription pharmacuticals; Th off-labl us of prscription pharmacuticals; and Pag Pag9 9

14 Th natur of unintndd consquncs in th us of prscription pharmacuticals. A numbr of mmbrs of NAC hav prsntd vidnc to th committ undr on or mor of th abov thms. In January 2014, th committ rlasd its first rport, Prscription Pharmacuticals in Canada: Off-Labl, including 18 rcommndations. Th rcommndations includ suggstions to improv drug lablling and prscribr ducation, as wll lmnts of monitoring and survillanc, which ar all consistnt with th rcommndations of th First Do No Harm Stratgy. Othr National Initiativs In March 2013, CCSA and svral NAC mmbrs participatd in a roundtabl mting of th Surviving Opioid Ovrdos with Naloxon (SOON) projct fundd by Canadian Instituts of Halth Rsarch (CIHR). SOON is a national intrdisciplinary collaboration of community stakholdrs, patint ladrs and knowldg usrs, along with contnt xprts from divrs clinical filds, mthodologists and industry. At this mting, participants rviwd th stat of th art in ovrdos rscu. Th initiativ will s th dvlopmnt of standardizd protocols, optimization of implmntation stratgis and th idntification of th bst mans to valuat outcoms. CCSA and othr mmbrs of th NAC continu to participat on th National Opioid Us Guidlin Group (NOUGG) of th National Faculty of th Michal G. DGroot National Pain Cntr in knowldg mobilization activitis rlatd to th Canadian Guidlin for Saf and Effctiv Us of Opioids in Chronic Non-Cancr Pain. This Guidlin and rlatd rsourcs, such as th Opioid Managr and Practic Toolkit, ar now availabl on th National Pain Cntr wbsit (nationalpaincntr.mcmastr.ca/guidlins.html). In rspons to a rqust for suggstions about gaps in th rgulations or improvmnts to thm, th First Do No Harm Excutiv Council submittd rcommndations to Halth Canada on th Controlld Drugs and Substancs Act (CDSA) and th xpandd scop of th National Anti-Drug Stratgy. Th group also draftd a rlatd lttr to Halth Canada to addrss idntifid aras for improvmnt in lablling and product monographs. S copis of th submissions in appndics B and C. Provincial/Trritorial Initiativs In addition to activitis at th national lvl, provincial initiativs ar undrway from coast to coast to addrss harms associatd with prscription drug us. Th British Columbia Cntr for Disas Control is closly following th rsults of thir nwly implmntd Tak-Hom Naloxon pilot program. In th first nin months sinc th program launchd in August of 2012, 14 ovrdos rvrsals wr rportd. A largly positiv rspons to th program has bn rportd among stakholdrs supporting its xpansion byond th thr halth authoritis in which it was pilotd. In addition, CCSA and othr NAC mmbrs ar part of th rsarch tam for th Scond Chancs study that will prform a mor thorough valuation of th program. Th implmntation of th program is consistnt with th Stratgy s rcommndations to rviw th vidnc on community-basd initiativs to rduc ovrdos and rlatd daths, and incras th implmntation of ffctiv initiativs. Albrta has bn a strong supportr of th First Do No Harm Stratgy, providing funding for a numbr of th projcts on which CCSA and th implmntation tams wr activly involvd. Dtails of ths initiativs ar providd in th nxt sction of this rport. In addition, th Collg of Physicians and Surgons in Albrta approvd prscribing changs for buprnorphin/naloxon to hlp rmov barrirs to patint car as st out in th Stratgy s rcommndations. In som cass, particularly for patints in hospitals or othr car sttings with controlld mdication dispnsing Pag Pag 10 10

15 procsss or for incarcratd patints, physicians no longr rquir a mthadon xmption to prscrib ths mdications. A numbr of activitis hav bn undrway in Ontario to addrss prscription drug harms. On of th most significant is an initiativ announcd by th Ontario Ministry of Halth and Long-Trm Car to crat a ral-tim survillanc systm to track ovrdos daths and injuris from approximatly 90 hospital mrgncy rooms. Th nw systm, xpctd to launch latr this yar, will allow public halth units to know in ral-tim if thr is a ris in opioid ovrdoss in thir community and plan thir rspons accordingly. Th dvlopmnt of a national prscription drug survillanc systm is a critical componnt of th First Do No Harm Stratgy. In arly 2013, th govrnmnt of Princ Edward Island rlasd a nw stratgy to addrss mntal halth. Undr this initiativ, th govrnmnt has agrd to invst $1.2 million in immdiat actions to addrss th ris in prscription drug addiction within th provinc. Th funds supportd th cration of a Chif Mntal Halth and Addictions Officr, nw prscribing guidlins to rduc misus of prscription drugs, a nw inspctor to invstigat irrgularitis in prscribing, xpandd mthadon tratmnt and accss to buprnorphin/naloxon, and a 10-bd transition unit to support patints aftr dtox. Th govrnmnt of Nova Scotia has also takn significant stps to addrss prscription drug harms in th provinc. Through its mntal halth and addictions stratgy, it is dircting funds to monitoring and survillanc fforts as wll as prscribr ducation through th Atlantic Mntoring Ntwork for Pain and Addiction. Enhancmnts to th Drug Information Systm (DIS) within th provinc prmit pharmacis to connct dirctly with th systm, allowing th PMP to rciv information dirctly from th DIS. Th provinc has usd information gathrd through its PMP to conduct a rviw of its Drug Utilization Rviw procss to adjust th critria for idntifying cass for inquiry. A quality improvmnt initiativ dirctd toward physicians who prscrib a larg proportion of th provincs opioids was also initiatd in th past yar. British Columbia s Ministry of Halth launchd a provincial acadmic dtailing modul, Opioids in Chronic Non-Cancr Pain (CNCP). This 30-minut continuing mdical ducation sssion involvs pharmacists mting with physicians on-on-on to discuss th bnfits and harms of opioids in CNCP, th importanc of an initial short-trm, structurd opioid trial, th charactristics of spcific opioids and opioid formulations, and th rol of opioid stwardship in improving patint and public safty. Multi-prongd initiativs lik thos of Princ Edward Island, British Columbia and Nova Scotia, consistnt with rcommndations from th Prvntion, Education, Tratmnt, Monitoring and Survillanc, and Enforcmnt strams of th Stratgy, rflct th intractabl natur of th prscription drug problm and th nd for a stratgic and coordinatd approach to hav an ffctiv impact. Pag Pag 11 11

16 Priority Rcommndations and Tam Activitis To focus thir fforts, th implmntation tams slctd priority rcommndations from th Stratgy that thy could action with th rsourcs availabl to thm. Th following subsctions summariz th slctd rcommndations and th actions takn in th first yar. Prvntion Rcommndation 3: Idntify, dvlop, promot and valuat vidnc-informd, culturally saf practics, rsourcs and policis to build community and individual capacity to addrss conditions that incras or protct against harms associatd with prscription drugs for municipalitis and communitis, particularly rural, isolatd and rmot communitis; and individuals and familis, including patint dcision aids rlatd to th tratmnt of chronic pain, th risk for addiction and th impact of misus. Th Institut for Saf Mdication Practics (ISMP) Canada has producd a rsourc to ducat patints and familis about opioid pain mdications and promot saf us, particularly during th transition from hospital to hom. Th Prvntion Tam is rviwing th rsourc and providing ISMP with fdback on th contnt. Th rviw will also valuat th applicability of th rsourc for us in othr sttings such as pharmacis to support patint ducation during th dispnsing procss. Th Prvntion Tam will idntify opportunitis to dvlop tailord vrsions of th rsourc for this and othr purposs. In Hamilton, Ontario, CCSA and othr tam mmbrs wr involvd in a sris of thr mtings to dvlop a local stratgy, A Practical Approach to Prscription Drug Misus and Divrsion, ld by th Michal G. DGroot National Pain Cntr and fundd by through a CIHR dissmination grant. This initiativ is dvloping a tmplat for communitis intrstd in taking collctiv action on this important halth and safty issu. To addrss prscription drug concrns at th municipal and community lvl, th Prvntion Tam idntifid partnrs working in this ara with whom thy hop to ngag in th coming yar. Th tam has approachd th Canadian Fdration of Municipalitis to discuss thir intrst in bcoming involvd in taking action on this rcommndation, particularly to addrss by-laws in som municipalitis that prohibit ndl xchang programs, suprvisd injction and consumption sits, and mthadon clinics. Th Prvntion Tam has also idntifid th National Nativ Addictions Partnrship Foundation as a critical partnr in xchanging information with First Nations communitis. Rcommndation 4: Dvlop, implmnt and valuat vidnc-informd prscription drug-rlatd social markting campaigns and rlatd rsourcs dirctd to spcific populations or communitis, including information about th bnfits, harms and limitations of us as prscribd and of nonmdical us; appropriat us; signs and symptoms of misus, addiction and ovrdos (and actions to b takn); saf storag and disposal; othr stratgis to prvnt harms (.g., rlatd to drugimpaird driving); and wllnss promotion and altrnativs to pain mdications (.g., slf-car stratgis). Social markting campaigns ar rsourc-intnsiv ndavours. To nsur that futur campaigns rlatd to prscription drug misus ar vidnc-informd and fill an idntifid nd, CCSA was fundd by Halth Canada to conduct an nvironmntal scan of xisting social markting campaigns rlatd to prscription drugs. Th rviw considrd th vidnc usd in dvloping th campaigns, as wll as th rsults of any valuations compltd on thir ffctivnss. Th rviw also idntifid th targt audincs and providd a gap analysis outlining th aras or audincs that currnt Pag Pag 12 12

17 campaigns ar not addrssing. Th rsults of this rviw can inform th dvlopmnt of targtd, vidnc-informd, ffctiv campaigns to addrss prscription drug harms in Canada. Rcommndation 6: Dvlop and promot guidlins for individuals and familis rlatd to th us, saf storag and disposal of prscription mdications. Guidlins should includ family assssmnt, community mdication disposal rsourcs and stratgis to addrss barrirs to saf storag (.g., lockd boxs) and disposal. Th Prvntion Tam xamind xisting guidlins rgarding th saf storag and disposal of mdications by pharmacis to idntify gaps and bst practics. A sarch by CCSA for xisting guidlins for pharmacis has now bn compltd and found a lack of consistncy across jurisdictions. Th tam is also rviwing fdral guidlins on mdication disposal as wll as xamining availabl rsarch rlatd to supply chain scurity. Ths rviws of xisting profssional and fdral guidlins in conjunction with xisting rsarch, will hlp idntify gaps whr guidlins nd to b dvlopd or improvd, and stablish bst practics for storag and disposal that should b promotd. Rcommndation 8: Rviw xisting vidnc and/or conduct objctiv and indpndnt rsarch and mak rcommndations on th ffctivnss, including cost-ffctivnss, of community-basd prvntion initiativs dsignd to rduc ovrdos and rlatd daths (.g., tak-hom naloxon programs). To xpand th body of knowldg rlatd to th ffctivnss of community-basd prvntion initiativs, an application was submittd for a CIHR Partnrships for Halth Systms Improvmnt grant for Th Scond Chancs Study: A Mixd Mthods Invstigation into th Effctivnss of Tak- Hom Naloxon Training for Popl at Risk of Opioid Ovrdos. Dr. Jan Buxton, from th Univrsity of British Columbia, is th study s principl invstigator. Two CCSA staff ar involvd as coinvstigators or knowldg usr co-applicants, as wll as svral NAC mmbrs. Th study will b focusd on British Columbia s Tak-Hom Naloxon program that was launchd in August Part of th Stratgy s rol is to shar larnings with othr jurisdictions and assist in local implmntation. Sharing th rsults of this study will provid an opportunity for othr provincs intrstd in stablishing similar programs to larn from British Columbia s xprinc. Rcommndation 10: Dvlop and valuat accssibl vidnc-informd rsourcs for practitionrs and ducators working with youth to hlp incorporat prscription drug-rlatd harm prvntion into programs and policis, whil nsuring that unintndd consquncs ar avoidd. This should includ population halth promotion initiativs that focus on asst building and th promotion of rsilinc; and building prscription drug-rlatd contnt into xisting prvntion initiativs by lvraging what alrady xists in communitis. In th intrst of lvraging xisting work, th Prvntion Tam has rviwd rsults of an nvironmntal scan of vidnc-informd rsourcs that incorporat th prvntion of prscription drug-rlatd harm into ducation programs. Th tam is rviwing th scan, conductd by Nova Scotia, to idntify practics to implmnt in othr jurisdictions. Ths rsults, in conjunction with th rsults of th Halth Canada-fundd scan of social markting campaigns and rlatd rsourcs focusd on youth, will hlp to build an invntory of rsourcs for practitionrs and ducators to incorporat prvntion mssaging into thir work with youth. Pag Pag 13 13

18 Education Rcommndation 1: Establish and implmnt cor comptncis for all typs of halthcar practitionrs in th assssmnt and managmnt of addictions, mntal halth, co-morbiditis, concurrnt disordrs and pain. Idntify xisting comptncis and standards of car to dtrmin th xtnt to which thy addrss th harms associatd with prscription drugs; dvlop comptncis with involvmnt from practitionrs, individuals, familis, industry and th community; work with ducators to mbd ths comptncis into th cor curricula for ach halthcar practitionr; nsur that cultural considrations ar rflctd in ths comptncis; includ comptncis rlatd to th provision of trauma-informd srvics; and includ comptncis rgarding undrstanding and influncing th dtrminants of halth and thir impact on patints prscription drug harms. Th Education Tam dvlopd an invntory of xisting comptncis and standards of car for a rang of halthcar practitionrs involvd in addictions, mntal halth, co-morbiditis, concurrnt disordrs and pain. A rviw of this invntory nabld th tam to dtrmin th xtnt to which ths xisting comptncis addrss th harms associatd with prscription drugs. Whil various disciplins hav dvlopd rlvant comptncis, no on st of comptncis comprhnsivly addrssd th full rang of skills rquird for appropriatly prscribing th mdications of concrn to th Stratgy. An initial st of comptncis was draftd and rviwd by th mmbrs of th multi-disciplinary Education Tam to addrss this gap. Following a numbr of rvisions, th comptncis ar now rady for broadr consultation, rviw and input by rlvant profssional associations, acadmic institutions and accrditing organizations. In addition, furthr outrach to a cross-sction of cultural groups is plannd to nsur cultural considrations ar adquatly rflctd in th comptncis th tam has dvlopd. Rcommndation 2: Dvlop accrditd halthcar practitionr continuing ducation programming spcific to th appropriat us of ths prscription drugs. Encourag rgulatory and ducational authoritis for prscribing and dispnsing halthcar practitionrs to adopt cor comptncis that affct th prvalnc and svrity of addiction and ovrdos, which includs patint slction, dos titration, monitoring and tapring. To addrss gaps in halthcar practitionr continuing ducation programming, th Education Tam undrtook an invntory of th rlvant ducational offrings for prscribing and dispnsing practitionrs. With funding providd by Halth Canada, an nvironmntal scan of xisting continuing ducation offrings for both groups was conductd. Th compltd scans will b usd to idntify whr th most significant gaps xist. Th tam will tak stps to addrss th gaps, ithr through th dvlopmnt of nw programs or through fforts to incras th availability and uptak of xisting quality cours offrings. To rcruit support and xprtis for th tam s ducation-rlatd initiativs, th tam will shar th Stratgy with undrgraduat ducation institutions, accrditation bodis, licnsing and rgulatory bodis for halthcar profssionals and profssional organizations (including dntists, nurss, pharmacists and physicians), commrcial providrs and ducational institutions rsponsibl for continuing ducation programs. Ths groups will b askd to idntify rprsntativs who can provid input on th Education Tam s suggstions to improv halthcar practitionr continuing ducation, as wll as othr tam initiativs. Pag Pag 14 14

19 NAC mmbrs ar part of a CIHR-fundd knowldg synthsis projct ld by Dr. Andra Furlan of th Univrsity of Toronto. CCSA s Dr. Amy Porath-Wallr and Education Tam co-lad Dr. Norm Buckly ar involvd as knowldg usrs on th Rsarch and Knowldg Exchang Tam. Th projct will conduct a systmatic rviw of xisting stratgis, framworks, collaborativ ntworks and matrials to promot th appropriat us of prscription opioids and rduc th abus of ths drugs; crat an opn-accss databas of all matrials found in th rviw; and idntify gaps, inconsistncs and duplication among stratgis to guid futur rsarch and practics. Rcommndation 3: Implmnt accssibl acadmic-dtailing programs (.g., RxFils Program in Saskatchwan) that provid vidnc-informd ducation on prscribing and dispnsing practics in all provincs and trritoris and valuat th ffctivnss and impact of ths programs. Link ths programs to prscription monitoring programs, whr possibl, to dtrmin chang in practic. Similar to addrssing gaps in continuing ducation, to improv accss to quality acadmic-dtailing programs in all provincs and trritoris, th Education Tam idntifid th nd to first stablish what programs wr alrady in plac and whthr any valuation work had bn compltd to stablish thir ffctivnss. Th tam dvlopd a list of xisting provincial acadmic dtailing programs, including information on what srvics thy offr and how ffctiv thy hav bn in influncing prscribr practic. Th nxt stps will b to rviw th information gathrd to idntify whr acadmic dtailing programs ar absnt and, basd on th xprinc of xisting programs, dtrmin what srvics nw programs should considr adopting and how xisting programs could b modifid to improv thir fficincy and ffctivnss. Rcommndation 8: Train and quip multidisciplinary practitionrs (.g., halthcar practitionrs, mrgncy mdical srvics, law nforcmnt, corrctions and addiction counsllors) to rcogniz and manag prscription drug ovrdoss With th support of Albrta Halth, CCSA mbarkd on a survy to bttr undrstand halth profssionals prcptions of prscription drug misus (PDM) and local stratgis for action. Th survy, issud to physicians, pharmacists, dntists and nurss practicing within th provinc of Albrta, assssd thir prcptions of th xtnt and distribution of PDM among thir patints, clinical manifstations and risk factors for PDM, barrirs to idntifying patints ngaging in PDM and stratgis for prvnting and addrssing PDM. Th rsults of this study will hlp inform th dvlopmnt of ducation and prvntion initiativs aimd at addrssing and rducing th harms associatd with PDM, such as addiction, ovrdos and dath. An xprt panl from Albrta is currntly analyzing survy rsults, with th final rport xpctd to b rlasd by summr Furthr discussions ar plannd with dcision makrs in Albrta to dtrmin th rquird stps for moving forward. Tratmnt Rcommndation 3: Idntify, dvlop, as ndd, promot and valuat funding mchanisms and incntivs that improv and promot accss to withdrawal managmnt programs, including in rural and rmot aras and for thos on opioid tratmnt or othr mdications. Albrta Halth providd funding to pilot and valuat an on-lin Mthadon Maintnanc Tratmnt (MMT) workshop for srvic providrs in its provinc. Th cours, bing dvlopd and hostd by th Collg of Physicians and Surgons of Albrta, is intndd to hlp improv accss to ffctiv mthadon maintnanc tratmnt srvics in undrsrvd and rmot jurisdictions across southrn Albrta with a viw to applying this approach in othr parts of Canada that hav similar challngs. As part of th workshop, an valuation will b conductd to compar th ffctivnss of th on-lin workshop with a similar fac-to-fac offring. Th Tratmnt Tam is also compiling Pag Pag 15 15

20 guidlins for th dlivry of MMT workshops, which will prov valuabl to organizations across Canada who dlivr similar training. Rcommndation 4: Promot th us of vidnc-informd guidlins for tratmnt of addiction, mntal illnss, co-morbiditis, concurrnt disordrs, and acut and chronic pain (including ffctiv non-pharmacological approachs). Dvlop nw or updat xisting guidlins as ndd with input from spcialty socitis (.g., mrgncy physicians, nurs practitionrs, family practitionrs) rprsnting various halthcar sttings; sarch for and apprais xisting guidlins; assss th adaptability of xisting guidlins to various sttings and/or th nd for nw guidlins; adapt guidlins as indicatd; dvlop nw guidlins as indicatd; and updat xisting guidlins as ndd. Tratmnt guidlins vary considrably by typ of tratmnt thy addrss, patint population, lvl of vidnc and jurisdiction. Simply idntifying th guidlins in us across Canada at both a provincial and national lvls has bn a significant task th Tratmnt Tam has undrtakn. Whil invntoris for a numbr of provincs ar complt, th tam is working to nsur that guidlins from all provincs and trritoris ar includd. Th nxt stps will b to apprais th guidlins and idntify mchanisms to shar bst practics across th country and dtrmin whr ffort should b dirctd to dvlop or updat xisting guidlins. Rcommndation 6: Idntify, dvlop, valuat and implmnt ffctiv, vidnc-informd scrning, brif intrvntion and rfrral to tratmnt for prscription drug harms that can b usd with or adaptd for a varity of patint groups (.g., thos with addiction, dpndnc, mntal halth, co-morbiditis, concurrnt disordrs, chronic pain, tc.). In addition to guidlins for tratmnt, th Tratmnt Tam is also gathring scrning, brif intrvntion and rfrral to tratmnt (SBIRT) approachs that ar bing usd across th country and could b adaptd for us in othr locations and with othr populations. CCSA and NAC mmbrs rcntly co-authord a rviw that valuatd th ffctivnss of xisting SBIRT approachs. Th rviw will b a valuabl foundation for th futur work of th tam and guid th nxt stps in adapting SBIRT approachs for us with a varity of patint groups. Monitoring and Survillanc Rcommndation 1: Standardiz th ky lmnts of a Canadian prscription drug survillanc systm, such as: data holdrs; data strams (.g., coronr rports, poison cntr rcords, IMS Halth data, losss and thfts data, post-markt survillanc rlatd to advrs vnts data, mdication incidnts); dfinitions and common trminology; indicators (xplor potntial linkags with othr projcts such as th National Tratmnt Indicators, Drug and Alcohol Ntwork of Survillanc Exprts, Canadian Tobacco, Alcohol and Drugs Survy and xisting provincial survillanc systms); collction mthods; rporting; and links with data systms for alcohol and othr drugs, as wll as risk factors and sntinl survillanc for local planning. Th Monitoring and Survillanc Tam has primarily bn focusd on scuring funding to support th implmntation of th rcommndations that fall within thir stram of action. To dvlop national standards for a drug survillanc systm, a consnsus xrcis is rquird to nsur that thos intrstd in adopting th standards ar involvd in th procss and supportiv of th final rsult. Th tam has scurd funding from th Nova Scotia Dpartmnt of Halth and Wllnss to host a mting of stakholdrs from across th country, including thos from th FPT Working Group on Prscription Drug Abus, and rprsntativs of prscription monitoring programs to initiat this work. Pag Pag 16 16

21 Manwhil, mmbrs of th tam hav mt with th U.S.-basd RADARS (Rsarchd Abus, Divrsion and Addiction-Rlatd Survillanc) group. Th group has significant xprinc in th survillanc ara and is rcptiv to working with th tam to dvlop a national survillanc systm for Canada. Rcommndation 3: Crat a Canadian community of practic for PMPs: idntify and shar ffctiv and vidnc-informd practics; stablish standardizd componnts of Canadian PMPs; lvrag rsourcs; bnfit from and shar with intrnational programs; collaborat on rsarch; ngag in knowldg xchang; provid knowldg and xprtis to jurisdictions intrstd in dvloping PMPs; and dtrmin th ffctivnss of spcific promising practics, such as ral-tim accss by prscribrs and dispnsrs. Similar to Rcommndation 1, th Monitoring and Survillanc Tam is prpard to host a mting of intrstd partis to kick-off a Canadian community of practic for PMPs. This practic group will likly mt initially in conjunction with th mtings rquird to standardiz lmnts for th national prscription drug survillanc systm outlind in Rcommndation 1, with som potntial ovrlap in th stakholdrs involvd in ach. Using funding mad availabl by Albrta Halth, a litratur rviw on th cor componnts of ffctiv PMPs is bing compltd. Th rviw updats a systmatic rviw assssing th vidnc bas for PMP bst practics and thn asssss Albrta s PMP as to how wll it incorporats ths bst practics to assist with continuous improvmnt and volution. Th rviw will provid a strong foundation for all provincs to stablish nw, or improv xisting, PMPs and crat consistncy in approachs to monitoring, data analyss and rlatd rsponss. Th FPT Working Group on Prscription Drug Abus has also prioritizd th stablishmnt of PMPs. Th group has agrd to work collaborativly with th Monitoring and Survillanc Tam, combining both th rsourcs and xprtis rquird to progrss in stablishing ffctiv PMPs in all jurisdictions. Rcommndation 7: Establish an ongoing formal program of rsarch on th ffctivnss of PMPs, cor componnts and impact, including unintndd consquncs. Monitoring and Survillanc Tam Lad, Dr. Bth Sproul, has scurd funding through Phas 1 of th CIHR Canadian Rsarch Initiativ in Substanc Misus (CRISM) program to dvlop a PMP Rsarch Ntwork. Phas 1 funding is dsignd to build tams of acadmic rsarchrs and srvic providrs around common projcts in substanc misus. Th funding will b usd to dvlop a tam that can support an ongoing formal program of rsarch on PMPs that can fd a continuous cycl of improvmnt for Canadian programs. Th fulfillmnt of ths Monitoring and Survillanc rcommndations will srv as th foundation for all futur tam implmntation activitis. Enforcmnt Rcommndation 1: Dtrmin th impact of addrssing illicit us, including th divrsion and trafficking of prscription drugs, on law nforcmnt rsourcs for policing and rlatd activitis, such as proscution and corrctions, and idntify spcific rcommndations for action to prvnt divrsion for criminal purposs. Conduct a cost-impact assssmnt rlatd to prscription drugs on law nforcmnt rsourcs and public safty. Public Safty Canada fundd a study to dtrmin th cost impact of prscription drugs on th Canadian criminal justic systm, including law nforcmnt, proscution srvics and corrctional srvics. Th study, launchd in arly 2013, was compltd at th nd of March 2014 and is a first stp in furthring our undrstanding of th full impact of illicit prscription drug us on Canada s Pag Pag 17 17