Illicit Use of Pharmaceuticals Workshop

Illicit Use of Pharmaceuticals Workshop PDF Version (410 KB)

Executive Summary

Purpose of this Document

The following report contains summaries of the presentations and discussions that occurred during the “Illicit Use of Pharmaceuticals” Workshop that was hosted by Public Safety Canada on June 2-3 2011.  The Workshop was held at the Sheraton Vancouver Airport Hotel in Vancouver, British Columbia.

The report includes summaries of each panel presentation and highlights the key messages, proposed strategies and suggested next steps that emerged throughout the Workshop.  It is intended as a reference document for Public Safety Canada and Workshop participants.

The views expressed herein are those raised by the speakers and participants at the Workshop and do not necessarily reflect those of Public Safety Canada or the Government of Canada.

Workshop Overview

The “Illicit Use of Pharmaceuticals” Workshop was hosted by Public Safety Canada to continue the dialogue on emerging issues in drug enforcement that was begun at a symposium in Montreal in November 2010.  The purpose of the Workshop was to share information, experience and expertise on the illicit use of pharmaceuticals to help participants grasp the complexity and scope of the issue, as well as to identify an appropriate framework for action.

The Workshop brought together approximately 100 delegates from across Canada, representing experts in drug enforcement from municipal, provincial/territorial and federal realms, as well as from the United States.  Participants from the health community were also present, including experts in pain management, representatives from public health agencies, as well as representatives from national and regional organizations of physicians and pharmacists.  The list of participants is available in Appendix A.

The agenda for the 2-day Workshop was divided into the following four sessions:

• Session I: Law Enforcement Perspectives
• Session II: Health Perspectives
• Session III: Integrated Responses
• Session IV: The Way Forward

The Workshop agenda can be found in Appendix B. PowerPoint decks that were presented by speakers at the Workshop are available upon request to the individual authors.

Key Messages

The issue of prescription narcotic misuse is a serious problem of growing proportions affecting many communities in Canada.  Responding to the impacts of drugs on the health and safety of communities is a complex and shared responsibility across various sectors.  The following key messages from law enforcement, health and integrated responses perspectives emerged throughout the 2-day Workshop:

Law Enforcement Perspectives

In recent years, law enforcement from Nova Scotia to British Columbia has seen a substantial increase in the misuse of prescription drugs.  Diversion happens from a number of different avenues, including doctor shopping, fraud, prescription theft and forgery.  The potential for profit from the street sale of prescription drugs makes it highly lucrative, and some individuals rely on the income generated from these sales.

The use of prescription drugs is strongly correlated with other street crimes such as theft, pharmacy robberies and residential breaking and entering.  Other impacts of drug misuse in society include overdose deaths, increase in number of suicides, and escalating health care and emergency care costs.  The increase in associated secondary crimes puts additional pressure on frontline officers.

Law enforcement across the country has encountered a number of investigative issues related to combating the trafficking of opioids.  First, the fact that prescription drugs can be legally possessed poses significant challenges to law enforcement investigating criminal distribution. Unlike traditional street drugs, mere possession with a prescription is not enough to prosecute an individual and significant additional police resources are required to build and prove a case.  A lack of subject matter expertise on the issue and insufficient law enforcement resources also contribute to the problem.

Since the majority of prescription drugs come from legitimate sources, it is very difficult to tackle the problem with enforcement measures alone.  Effective communication channels must be established between law enforcement, pharmacists, physicians and other key stakeholders on diversion or subjects involved in diversion to address prescription drug misuse in Canada.

Health Perspectives

Prescription opioids present a unique health and policy challenge in the country because they are critically important for severe and chronic pain treatment.  Because they are covered under medical plans, they are easy to obtain, and since they come from legitimate sources, there is a perception among the public that they are less serious than illicit drugs.

Medical coverage plays a major role behind a physician's decision to prescribe opioids for pain management.  Although the drugs have addictive qualities and can result in withdrawal symptoms after only 3 weeks of regular use at a prescribed dosage, they are prescribed because of a lack of other pain management options (counseling and physiotherapy are rarely covered under provincial health plans).

Because there are no independent measures of pain, it is very difficult for physicians to determine whether or not a patient is faking pain symptoms.  Overprescribing often occurs as a result of a lack of education, training and awareness on how to effectively prescribe for acute or chronic pain.  Medical curriculums in Canada must provide much better education on pharmaceuticals, drug interactions, mental health and addiction.  The use of shorter dispensing intervals and guidelines for prescribing addictive medications may also significantly contribute to improving prescribing practices.

The shortage of physicians throughout Canada represents a significant barrier as it means physicians and pharmacists have very little time and ability to follow-up with a patient to ensure the medication prescribed is being used properly.  In addition, it is not always clear what resources are available to help physicians and pharmacists address concerns related to prescription monitoring should they arise.

There is also a very limited capacity to track and share information between physicians, pharmacists, law enforcement and other key stakeholders.  From the perspective of a regulator, one of the difficulties and barriers related to drug misuse, abuse, diversion and prescription monitoring is privacy legislation, which puts limitations on how the data collected is used, stored and shared with other key partners.

Prescription monitoring programs may be a key component of a comprehensive strategy to address prescription drug misuse.  Physicians and pharmacists must have ready access to current, up-to-date information to be able to use such programs in their daily practice and to help them determine whether or not dispensing a drug to a certain patient is appropriate.  More research, however, is needed on the effectiveness of prescription monitoring programs and what their impacts are on addressing the problem.

Pain care specialists, physicians and pharmacists are committed to participating in the reduction of health care fraud as it would allow them to better focus on the needs of patients requiring care.  Addiction issues are not simple to address, and studies demonstrate the co-existence of pain problems and mental health issues among those misusing prescription opioids. There is a significant lack of prevention, addiction and mental health treatment services throughout the country.  More resources and funding must be invested in these services to shorten wait times and lengthen treatment time.  Increasing access to alternative treatments for pain management may also be a key part of the solution.

Integrated Responses

Prescription drug misuse is a complex community issue requiring a comprehensive, multi-faceted strategy, a multi-pronged approach and a target-based communication plan.  An effective strategy should be based on local evidence, consider best practices, be flexible and adaptable to local situations, clearly delineate the role of stakeholders involved at all levels and consider the target audience.

Strategic partnerships with community groups are a key part of a comprehensive strategy.  Partnerships should be established with as many relevant partners as possible in order to maximize efforts, pool resources, build capacity and develop common messaging.  Partners could and should include: school boards, youth workers, native centres, centres for addiction and mental health, addiction and treatment services, community health centres, emergency medical services, health system, dental associations, health professionals (physicians, pharmacists, coroners, oral surgeons) and public health representatives.

One of the best ways to address prescription drug misuse is through public education and prevention.  It is important to communicate with users and other local community members who are directly affected by drug misuse to understand the motivation behind their actions and to determine appropriate measures to address the problem.  Focus groups with community stakeholders are another great way of gaining a better understanding of other perspectives on the issue.

In the end, successful outcomes lie in creating a common understanding and shared responsibility for action across professional disciplines and within communities.  Encouraging stakeholders to look at their own spheres of influence to identify what they can do as individuals and as part of communities is a critical part of the process.  It is also important to establish mechanisms for sharing information on what is happening on the ground.  Working together in a coordinated way to increase public awareness, improve the knowledge base, increase professional capacity, and effect policy changes is imperative to addressing drug misuse.  Finally, continuous monitoring and evaluation is a key component of any strategy.

Moving Forward

The drug misuse problem needs concerted attention and a collective intervention strategy that focuses on reducing the volume of prescription opioids in the population and addressing drug misuse without undermining the availability and quality of pain care.  It will be important to start connecting the dots between all relevant stakeholders, including: law enforcement, prevention, emergency care, coroner's offices, pain specialists, addiction specialists, prevention specialists, pharmacists, prescribers, regulatory bodies, corrections, school boards, universities and community organizations.

A comprehensive strategy needs to include prevention and education, treatment, policy/regulations and enforcement.  Key components of a comprehensive strategy include:

• A balanced and comprehensive approach that builds on current strengths.
• Clear, realistic, measurable short-term and long-term goals based on evidence.
• Collaborative leadership (from both the public safety and public health perspectives).
• A sustained funding commitment.
• Research and evaluation.
• A federal and provincial mandate to move forward.

Next Steps

At the end of the 2-day Workshop, the group committed to moving the issue forward on a national level and agreed on the following next steps:

• Organize an initial meeting with all interested parties to begin to plan the way forward.
• Identify key stakeholder groups covering health, treatment, enforcement and policy perspectives that will help move this forward nationally.
• Establish a collective plan and identify key action steps, building on key messages and commitments for action that emerged from the Workshop.
• Create a community of practice to share information and discuss immediate needs and opportunities.

Background and Context

Opening Remarks

Yves Leguerrier, Director of the Serious & Organized Crime Division at Public Safety Canada, welcomed participants to the meeting and made the following introductory remarks:

I'm pleased to be here today to welcome you, on behalf of Public Safety Canada, to our Workshop on the Illicit Use of Pharmaceuticals.  My Department has the lead responsibility for the Enforcement Action Plan component of Canada's National Anti-Drug Strategy. This means working closely with our partners, including the RCMP, the Department of Justice and Health Canada, in ensuring a coordinated federal response in the area of drug enforcement.

The Strategy itself is up for renewal in 2012, and this represents a significant opportunity; both to take stock of current trends in drug abuse and drug-related crime in Canada, and to identify emerging issues of concern to be considered and prioritized as part of a renewed Strategy. To move forward effectively, we need to hear from those of you on the front lines of the issues.

This past November, Public Safety hosted a Workshop on “Emerging Issues in Drug Enforcement” in Montreal, in order to begin this dialogue. We wanted to engage law enforcement and other experts from across Canada in identifying issues of concern in their jurisdictions. In a country as vast as ours, the most current and pressing drug-related issues sometimes vary, but to the extent that trends travel, we may also have the opportunity to use the experience at one end of the country to inform a proactive response at the other. We were extremely pleased with the outcomes of the November Workshop and the important discussion it generated; however, it became abundantly clear that prescription drug misuse represented an issue in need of further discussion, as either an urgent or growing concern in communities right across Canada. This problem does not have a single profile: whether it be fraudulent use of the health care system, prescription drug trafficking, pharmacy robberies, drug-impaired driving, or dealing with the serious impacts of prescription drug addiction on individuals and their families, it is clear that we must begin working more concertedly to address the range of challenges. At the same time, we must monitor the unintended consequences of our efforts as it relates to access to prescription drugs.

As everyone in this room is aware, responding to the impacts of drugs on the health and safety of communities is a complex and shared responsibility across various sectors, and this applies most especially to dealing with “licit” pharmaceutical drugs. Many of the participants in this room represent experts in drug enforcement, from municipal, provincial/territorial and federal realms, as well as from the United States; and we are also pleased to welcome participants from the health community, including experts in pain management, public health agencies, and representatives from national and regional organizations of physicians and pharmacists. I am pleased to say that we have representation from virtually right across the country.

With everyone in one room, we would like to continue the dialogue started in Montreal, in order to grasp the complexity and scope of the issue, as well as to identify an appropriate framework for action.

The issue of prescription drug misuse has proven difficult to define in terms of anchoring a response; its causes and effects are multifaceted, and as such our response must reflect this – we cannot look to law enforcement agencies or public health officials or physicians or pharmacists acting alone. What we have attempted to do with this Workshop is to provide a forum for various sides of this issue to be heard based on the realities from very different perspectives, and to showcase promising practices already being implemented where enforcement and health sectors are collaborating, through cooperating in investigative operations, collaborating to raise awareness, or creating community coalitions.

I would like to take a moment to acknowledge a community leader and colleague, who has been instrumental in raising the profile of the pharmaceutical abuse issue in Canada - Cape Breton Regional Police Chief Myles Burke. As many of you may be aware, Chief Burke passed away suddenly on April 9th of this year at 49 years of age, and this deep loss has been felt throughout his community and his colleagues in policing across the country.  In many ways, it was Chief Burke's passion for the issue of pharmaceutical misuse that made many of us take notice of it as a significant emerging problem over the past several years.  This includes his work with the Canadian Association of Chiefs of Police Drug Abuse Committee. At our fall Workshop in Montreal, he delivered a presentation on the problems his community faced in relation to oxycodone, and the successful community-based response. What was clear was his dedication to Cape Breton, and to this issue.  Chief Burke was the first person we called when we began planning this event, and he was scheduled to introduce tomorrow's session. We are deeply saddened by this loss, and dedicate the next two days to advancing the goals of a respected leader.

You are all here today because you have a particular point of view that is essential to both defining and moving forward on the issue of pharmaceutical misuse. We hope that during our facilitated discussions, which will take place in the afternoons after we have had the chance to hear various perspectives, that you feel encouraged to share your experiences, challenges and solutions. Over the next two days, I hope we can achieve the understanding necessary to allow us to begin charting a course of action, and that everyone here will gain knowledge and take away concrete ideas for action.

Once again, on behalf of Public Safety Canada, and my team in the Serious & Organized Crime Division in Ottawa who have organized this event, I want to thank you for taking the time out of your schedules to join us in this important dialogue. I wish you an informative and productive two days.

Overview of Non-medical Use and Diversion of Prescription Drugs

To set the context, leading expert Dr. Benedikt Fischer, from Simon Fraser University, provided an overview of the non-medical use and diversion of prescription drugs in Canada. Highlights of his presentation can be found below.

Prescription opioids are a unique health and policy challenge in Canada.  Over the last 20 years, there has been an explosion of the amount of oxycodone and other prescription opioids produced in the world.  The use of heroin has virtually disappeared and been replaced by prescription opioids, which are now dominating street drug-use scenes.  Many studies have revealed that mental health and pain problems are highly prevalent among users.

Deaths related to prescription opioids are on the rise.  There is an extremely strong correlation between the overall volume of prescription opioids dispensed in the population and harm levels such as morbidity and mortality problems.  Since oxycodone became widely available in Ontario, deaths related to the use of long-acting oxycodone have risen significantly.  Although oxycodone is a key part of the drug problem in Canada, it is not by itself the full extent of the problem.

Informal pathways are facilitating the bulk of the non-medical use of opioids: the majority of users obtain these drugs from a friend or relative.  The non-medical use of opioids is fuelled by diversion, which is a very heterogeneous phenomenon.  It happens from a number of different avenues, including; doctor shopping, prescription theft and forgery, as well as residential burglary.  Although prescription monitoring reduces the overall consumption level of opioids in a population, there is no conclusive evidence that they prevent non-medical use or opioid-related problems.  It is difficult to determine the full extent of the problem in Canada due to the lack of data available and the absence of a national data repository.

Prescription opioid misuse and harms are clearly a major substance use and public health challenge in Canada.  It produces a higher burden of disease than all other illicit drugs put together and represents a sizeable part of the drug problem in Canada; however, prescription opioids are critically important for severe and chronic pain treatment, which is a neglected care arena in Canada.  The problem needs concerted attention and a concerted intervention strategy that focuses on reducing the volume of prescription opioids in the population and addressing drug misuse without undermining the availability and quality of pain care.  It will be important to develop more effective general prevention strategies and more effective prescription monitoring programs to reduce the access to prescription opioids.  The interventions being put in place will also need to be carefully evaluated and monitored.

The illicit use of pharmaceuticals is a public health issue that is difficult to tackle through enforcement measures.  Although important progress has been made in understanding this issue in recent years, a number of intersecting vectors must be considered in analyzing the problem and identifying policy solutions that will address it.  Law enforcement is an important aspect of the solution but a successful approach will require the collaboration of law enforcement agencies, public health officials, physicians and pharmacists.  Enforcement and health sectors will need to cooperate in investigative operations, in creating community coalitions and in raising awareness about the illicit use of pharmaceuticals in Canada.

Session I: Law Enforcement Perspectives

To begin the session on law enforcement perspectives, Mark Mander, MBA, Chief of Police of Kentville Police Service, provided an overview of the impact of prescribing in Nova Scotia.  Following this presentation, Detective Sergeant Rick Hawley from the Ontario Provincial Police provided an overview of oxycodone misuse in Ontario.  To frame the problem from another perspective, David F. Lenartowicz, from the United States Drug Enforcement Administration (DEA), discussed trends and operational responses to illicit pharmaceuticals in the United States.

1.1 Drugs on the Street: The unintended impact of prescribing in Nova Scotia

The prescription drug abuse problem in Nova Scotia has exploded over the last 8 years, yet it is an “unspoken pandemic.”  Few people talk about the severe impacts that prescribing opioids is having on local communities.  These impacts range from accidental deaths and suicides, to increased crime rates and an increased risk of other health issues such as HIV/AIDS and hepatitis.  Although Organized Crime groups are not currently involved in the illegal distribution of prescription pills in Nova Scotia, there are some concerns that they may become interested if the profitability of distributing these drugs increases.  Once these groups become involved, it will be very difficult to eradicate them.

Although demand varies by region, the drugs of choice in Nova Scotia are opiate pain killers such as hydromorphone, opioids (e.g. Percocet, OxyContin) and methadone.  The majority of these drugs come from legitimate sources, which makes it very difficult to tackle the problem through law enforcement measures.  Sources of supply include doctor shopping and script purchasing, but pills are also being imported from other jurisdictions. When the supply from traditional sources slows, the rate of pharmacy robberies, breaking and entering and theft increases.

Law enforcement in Nova Scotia has encountered a number of investigative issues related to combating the trafficking of opioids.  First, there is a lack of available evidence due to the fact that the majority of opioids come from legitimate sources and witnesses are often unwilling to come forward.  There is also a significant lack of a coordinated multi-agency use of resources, as well as a lack of subject matter experts who can assist the police agencies with enforcement strategies and assist in the development of a broader community response to this very complicated issue.

A prescription monitoring program has been put in place in Nova Scotia to help reduce the number of prescription opioids.  As a result, the issue of “double-doctoring” has been largely eliminated.  Under this monitoring system, there has been success in the development of new ways to share information, such as police charge notifications; however the program is not a silver bullet, and it can only address one component of the problem.

In the future, the creation of more strategic partnerships between law enforcement, pharmacists, physicians and other health care providers will be critical in addressing the drug abuse problem in Nova Scotia.  These potential partners are currently working in silos and often lack the ability to share information with each other.

1.2 Oxycodone in Ontario

In recent years, law enforcement in Ontario has seen a substantial increase in the amount of prescription drugs seized, both by uniform patrol officers during vehicle stops and by drug officers during the execution of search warrants on homes.  The majority of these prescription drugs are of the opiate family, such as oxycodone, which is a highly addictive synthetic opiate that is available in Ontario by prescription for pain treatment.  OxyContin is a time-release form of oxycodone that was developed for people needing around-the-clock pain relief.  In Canada, OxyContin pills come with 10, 20, 40 or 80mg of oxycodone.  Just one OxyContin pill can have the same amount of oxycodone as 16 Percocet pills.  Users obtain the drug from a number of sources, including over prescribing, double doctoring, pharmacy robberies and thefts from homes.  They will most often chew, smoke or inject it.

Oxycodone abuse has become a major problem in Ontario for both law enforcement and health officials.  Oxycodone-related deaths in Ontario have more than doubled over the past five years.  The total number of deaths for the period of 2004-2008 was 464, which is nearly 10 times the rate for heroin.  The Ministry of Health and Long Term Care reports that in 2008, doctors in Ontario prescribed $54 Million dollars worth of OxyContin under the provincial drug program, triple the amount prescribed in 2004.  This number does not account for drugs prescribed to patients who have private drug plans.

While oxycodone seizure statistics vary by region, it appears to be relatively equally distributed throughout the province.  Information collected from confidential sources indicates that the use of oxycodone and the number of persons involved in illicit distribution is rising.  The ease of obtaining a drug that is readily available at any pharmacy makes it an attractive commodity.  In addition, the addictive nature of the drug guarantees repeat customers and consistent demand.

The potential for profit from the street sale of oxycodone makes it highly lucrative for individual criminals and organized crime groups.  Under a drug plan, a bottle of 100 80mg oxycodone can be purchased at a pharmacy with a forged or legitimate prescription for as little as a $4.00 dispensing fee.  If sold on the street, this results in a minimum profit of $3,996 per bottle.  This cost depends on a number of factors, including the geographical location of the users, the level of demand and availability, and the volume of the drug purchased.

Despite law enforcement efforts, the oxycodone problems persist in Ontario.  Police are faced with a growing number of dealers and street sources of the drug.  The use of oxycodone is also strongly correlated with other street crimes such as robberies and breaking and entering.  The increase in associated secondary crimes puts additional pressure on police resources.  The fact that oxycodone can be legally possessed poses challenges to law enforcement investigating criminal distribution.  Unlike traditional street drugs, mere possession with a prescription is not enough for prosecution, and significant additional police resources are required to build and prove a case.

As a result of the highly addictive nature of oxycodone and the steady rise in use of the drug, oxycodone abuse is a serious threat to Ontario communities.

An increase in education and awareness on the detrimental effects of the drug could have a major impact on the oxycodone issue in Ontario.

1.3 Illicit Pharmaceuticals in the United States: Trends and Operational Responses

Prescription drug abuse has always existed, but it is now the United States' fastest growing drug problem and has been classified as an “epidemic.”  In 2007, 27,658 unintentional drug overdose deaths occurred in the United States: Opioids were involved in more overdose deaths than cocaine and heroin combined.

Prescription opioids are obtained through various methods of diversion, including prescription fraud and doctor shopping.  Doctor shopping occurs when an individual or trafficking organization visits multiple doctors within a specific time frame in order to obtain a specific drug from more than one doctor.  Their illicit activitiesare usually facilitated by physicians operating out of “rogue pain clinics” and their affiliated pharmacies.

Rogue Pain Clinics, often referred to as “pill mills”, are opening and operating throughout all regions of the United States under the guise of providing “pain management.”  The US Drug Enforcement Administration (DEA) has identified three major hubs across the United States, including: Houston, Texas; Los Angeles, California; and South Florida.  Over recent years, South Florida has become the “pill mill” capital of the United States, being the chief supplier of oxycodone.

The Pill Mill Crackdown Act was introduced in March 14, 2011 to address the growing epidemic of prescription drug abuse by cracking down on the healthcare providers who prescribe medically unnecessary painkillers and supporting law enforcement in their efforts to identify and stop illegal activities.  The legislation doubles the prison sentence for operating pill mills from 10 to 20 years, and triples the fine from $1 million to $3 million.  The act also proposes to reclassify hydrocodone combination drugs as Schedule II.  The act specifies that assets seized from these drug dealers will be used to support prescription drug databases that are intended to prevent the illegal dispensing of prescription medicines.

Since abusers can and do obtain drugs from their own medicine cabinet, proper medical disposal is very effective, in combination with education and enforcement strategies, in addressing prescription drug abuse.  The DEA organized the first “National Take-Back Day” on September 25th 2010 in an effort to prevent unneeded prescription drugs from being introduced to the illicit market.  Over 4,000 locations and 3,000 law enforcement agencies throughout the United States participated.  They successfully collected 242,000 pounds of prescription drugs.

Session II: Health Perspectives

To begin the session on health perspectives, Professor Norm Buckley, from the Michael G DeGroote School of Medicine at McMaster University, described the legitimate uses for prescription opioids and explained the reasoning behind the use of these medications.  Following this, Ray Joubert, Registrar of the Saskatchewan College of Pharmacists, provided an overview of issues from a regulator's perspective on behalf of the National Association of Pharmacy Regulatory Authorities (NAPRA).  To provide further context on the issue, Aaron Gilson, Senior Scientist at the School of Medicine and Public Health from the University of Wisconsin, provided an overview of the impacts of prescription monitoring programs in the United States.

2.1 The Case for Psychotropic Pharmaceuticals

Chronic pain costs more to the country in health care costs and lost income than any other condition in Canada.  Patients deserve to have their chronic pain treated and opioids can be a useful and appropriate treatment option.  According to the medical model, disease or illness is a result of some injury to or derangement of usual physiological processes, which can be returned to normal function by some form of treatment.  Diagnosis is based upon characteristic symptoms of the disease supported by lab tests or other investigations.

One of the reasons physicians prescribe opioids is that the medical model traditionally works: A physician sees a patient with a problem, makes a diagnosis, prescribes a medication and the patient typically tends to get better.  Opioids are one of the more effective means of treating pain.  As there are no independent measures of pain, it is very difficult to determine whether or not a patient is faking the symptoms they describe, or perhaps even honestly misinterpreting some form of sensation or emotion.  Physicians are trained to believe their patients and deception is not usually considered until the drug abuse situation becomes clear through some other source of information at a later stage.  Even in these cases, physicians rarely get feedback from law enforcement if a drug abuse situation arises down the line.

Medical coverage also plays a major role behind a physician's decision to prescribe opioids including OxyContin for pain management.  Counseling and physiotherapy are rarely covered options under provincial health plans, while OxyContin is.  Other non-opioid pain treatment alternatives may also not be covered by some provincial formularies.  It also takes a lot less time to write a prescription than to discuss the requirements and benefits of physiotherapy with a patient, which allows physicians to help as many patients as possible in one day.  In addition, sometimes the alternatives to these medications produce serious side effects.

Many opportunities exist to improve the way physicians are prescribing opioids within the confines of the medical model.  In April 2010, Canadian medical regulatory authorities published a guideline to assist physicians in managing patients with chronic non-cancer pain by prescribing opioids in a safe and effective manner.  The guideline was developed in response to a growing concern about opioid misuse and related public health issues.  The Canadian Pain Society has also published a national pain strategy that establishes pain as a pan-Canadian problem.

Guidelines and strategies are critical steps to raising awareness about pain management issues in Canada and addressing prescription opioid misuse.  Collaboration among Canadian physician organizations, law enforcement and pharmacy organizations will be important.

2.2 Prescription Monitoring in Canada

The National Association of Pharmacy Regulatory Authorities (NAPRA) facilitates the adoption and implementation of best regulatory practices in all pharmacy regulatory authorities in Canada.  It develops model standards and guidelines, serves as a forum to discuss regulatory issues and acts as a common voice on national issues.

From the perspective of a regulator, one of the difficulties and barriers related to drug misuse, abuse, diversion and prescription monitoring is privacy legislation, which puts limitations on how the data collected is used and shared with other key partners.  These barriers also create limitations on how the data can be stored.  In addition, there are some challenges related to the lack of clarity of the roles and responsibilities of all the players involved.  It is not always clear what resources are available to help pharmacists in addressing issues related to prescription monitoring.

Health professionals need more guidelines like the Canadian Guideline for the Safe and Effective Use of Opioids for Chronic Non-Cancer Pain that was recently published.  A lack of resources, including technological support is also a current challenge, as well as outdated regulations under the Controlled Drugs and Substances Act (CDSA), and a lack of authority over specific areas of federal legislation.

Moving forward, more research is needed on the effectiveness of prescription monitoring programs and what their impacts are on addressing the problem.  There is also a need to create a vision for the future inspired by experience gained in Canada and in other countries, remembering that public safety must guide the discussions.

In conclusion, this issue does not belong to pharmacists alone.  Many other stakeholders need to be involved.  Better coordination among these stakeholders is required at all levels.  

Greater leadership from federal legislators, as well as more research and discussions on the issues and how to address them, are needed.

2.3 Impacts of Prescription Monitoring Programs in the United States

The non-medical use of prescription opioids is a public health imperative in the United States.  It is recognized that one of the key sources of diversion of prescription medications is doctor shopping.  In order to address this diversion source, Prescription Monitoring Programs (PMP) have been implemented in 36 states.  The primary objective of these programs is to reduce abuse and diversion, often with the explicit goal of not hindering patient care.  Through these programs, pharmacists enter information about dispensed medications into an electronic database.  This database generally can then be accessed by all prescribers and pharmacists to determine whether patients are acquiring additional medications from other practitioners.

PMPs are mostly administered by health agencies, usually a board of health or a pharmacy.  Such programs currently are very heterogeneous, but there are efforts underway to enhance their uniformity and promote across-state information exchange.  In the past, these programs were categorized by the use of government-issued specialized prescription forms that applied only to Schedule II medications.  Research suggests that programs focusing on a single medication class can result in a “substitution effect” resulting in a decrease in the prescribing of Schedule II medications because practitioners start prescribing medications that the programs do not cover.  It is essential that PMPs avoid having a sustained reduction in the availability of prescribed opioids for legitimate medical purposes.

Although PMPs can be an important mechanism to reduce the non-medical use of prescription medications, they only function to decrease diversion resulting from prescribing or dispensing practices.   Consequently, PMPs are not sufficient in themselves to address the complex problem of non-medical prescription opioid use because they do not address all sources of diversion, and rather should be considered part of a comprehensive strategy.

In conclusion, practitioners must have ready access to current and accurate PMP information for use in their daily practice and to help them determine whether prescribing a drug to a certain patient is appropriate.  Guidelines need to be developed for practitioners to direct them how to interpret the data they receive from the program and how to best utilize the program in their clinical practice.  There is also a need to improve practitioner awareness so they can make it an effective clinical practice tool and become a significant voice in the program enhancement process.  An authority to oversee program operation and evaluation of outcomes, as well as to ensure the accuracy of the data entered into the system, is also necessary.  These actions constitute a crucial step in the process of effectively reducing the public health problem of medication abuse and diversion.

Session III: Integrated Responses

To begin the session on integrated responses, Cst. Evan Anderson, from RCMP “F “Division Yorkton General Investigations, and Doug Spitzig, Pharmacist Manager from the College of Physicians and Surgeons of Saskatchewan (CPSS) provided an overview of their collaboration on a prescription pill drug trafficking investigation.  Following this, Erin McGinnis of Niagara Region Public Health and Det/Cst Terry Thomson of the Niagara Regional Police Service presented on their comprehensive community response to prescription drug abuse. Finally, Sgt Donna Hanson and Sgt Lorne Adamitz of RCMP “K” Division presented on the work being done by the Alberta Coalition on Prescription Drug Misuse.

3.1 Project FABLY: Prescription Drug Trafficking Investigation

Project FABLY was undertaken as a result of an increase in the number of intravenous drug users in the community, an outcry of public concern due to needles being found in the streets, an increase in suicides and drug overdoses, and an overall increase in violent crime.

The following agencies partnered to target prescription drugs in the Kamsack and Yorkton area of Saskatchewan: Yorkton RCMP General Investigation Unit; Kamsack RCMP Detachment; Yorkton Municipal RCMP Detachment; Canora RCMP Detachment; College of Physicians and Surgeons of Saskatchewan; and Saskatchewan College of Pharmacists.

Planning for Project FABLY began with a review of crime trends in the Kamsack and Yorkton area. Intelligence and information was gathered from confidential human sources, prescription drug abusers were interviewed and drug traffickers in the surrounding communities were monitored.  As a result of the project, 23 adults between 29 and 79 years of age were charged with various offences, including trafficking, identify fraud and theft, proceeds of crime and double doctoring.  Release conditions prevented a lot of the accused from frequenting the downtown core where they used to sell drugs.  They also made the accused more accountable for their actions and allowed police to search them at any time.

Some of the diversion tactics uncovered during the project include users convincing doctors that they had severe pain and selling their own prescriptions at street level prices.  These users are able to act out the signs and symptoms for various types of pain conditions.  Some users were purchasing in bulk from the prescriptions of others, or establishing false identities with several doctors to obtain prescriptions.

One of the lessons learned from the project is that it is important for law enforcement, Prescription Monitoring Programs, and pharmacists to share information on the types of drugs being diverted and the amount of prescriptions being dispensed from each pharmacy.  It is also important for pharmacists to help educate police on prescription medication.

Following Project FABLY, meetings were held with various community stakeholders, including sexual assault services, Public Health officials, the College of Pharmacists, the College of Physicians and Surgeons, social services, mental health and addiction services, the Ministry of Health, health networks, a provincial methadone program, the RCMP and Indian nations.

From these meetings, a working group was formed including many of these agencies as well as members of the Yorkton Tribal Council and representation from the First Nation Bands around Kamsack and Yorkton.  This group is still working to implement change and assist in helping those affected by prescription addiction and abuse.

Best practices identified during the project include: the establishment of a mandatory pharmacy information program by all pharmacists and doctors, and requiring patients to show photo identification when picking up prescriptions.  The sharing of information between police, pharmacists and doctors on diversion techniques is also a key part of the solution.  In addition, doctors should use electronic prescriptions to reduce theft and forging of prescriptions.

3.2 Comprehensive Community Response to Prescription Drug Misuse

Substance misuse has become an emerging trend and a growing community concern in the Niagara region.  To determine the extent of the problem, a series of external consultations, internal consultations and literature reviews were undertaken.  External consultations included focus groups and meetings with various community partners, agencies and organizations to obtain their perspectives and gain further insight on the issues associated with drug misuse. Partners involved included school board and health representatives, pharmacists, the Centre for Addiction and Mental Health (CAMH), and the Niagara Regional Police Service.

Some of the key findings from the external consultations were that drug misuse is not only a growing problem from a law enforcement perspective, but that schools have also identified the issue as a problem.  Pharmacists have expressed their frustration at being the middle man between doctors and patients, and have had first-hand experiences with violence and theft.  All stakeholders agreed that the issue of drug misuse would continue to grow without an effective intervention strategy.

Stakeholders at these meetings agreed that a cultural shift around prescribing, storage and disposal practices was required in the Niagara community.  A comprehensive health promotion strategy was recommended to re-orient community stakeholders around the drug misuse problem and to raise the profile of drug safety in the Niagara community.  It was decided that the strategy would be co-led between the Niagara Regional Police Service and Niagara Region Public Health, with Public Health taking a lead role in the development and implementation of the marketing and communication aspects of the drug misuse strategy while police services lead the investigation and enforcement initiatives.

The multi-pronged strategy that was used had three key directions: community capacity-building, communications and social marketing, and research and evaluation.  The strategy included an education and awareness component in the form of presentations to orient stakeholders and increase their knowledge and skills.  It also provided partner training and skill building opportunities for dentists, physicians and pharmacists.  The main components of the communications and social marketing campaign are still in development and will be launched this coming fall, and will include a website and a Facebook group.  The campaign also will entail media advertising and paid publicity.

It was agreed that an effective campaign would be based on local evidence, consider best practices, be flexible and adaptable to local situations, clearly delineate the role of stakeholders involved at all levels and consider the target audience.  The following target audiences were identified and marketing materials have been tailored to a number of these groups: the general public, seniors, parents, guardians, youth, health professionals, workplaces, educators, community agencies/partners and international PHD regional staff.  Community partner members and key stakeholders provided ongoing support throughout the campaign.  In addition, continuous evaluation allowed the campaign to be responsive and adaptable to community needs and opportunities.  The use of this multi-pronged marketing and communication approach has been effective in reaching all target audiences.

The formation of partnerships was a key element of the strategy.  It was recommended that partnerships be established with as many relevant partners as possible in order to maximize efforts, pool resources, build capacity and develop common messaging. Partnerships were formed with: school boards, youth workers, native centres, centres for addiction and mental health, addiction and treatment services, community health centres, emergency medical services, health system, dental associations, health professionals (physicians, pharmacists, coroners, oral surgeons) , police and Public Health.

Another key component of the strategy will be the continuous monitoring and evaluation of rates of drug misuse, public knowledge and behaviour change, the effectiveness of partnerships and the number of pills disposed of. In conclusion, drug misuse is a complex community-based issue requiring a comprehensive, multi-faceted strategy, a multi-pronged approach and involving a target-based communication plan.  Any community wishing to implement a comparable campaign should consider using a similar strategy and community-based approach to achieve success.

3.3 Alberta Coalition on Prescription Drug Misuse

The issue of prescription drug misuse is a serious problem of growing proportions affecting almost every community in Alberta. The Coalition on Prescription Drug Misuse (CoOPDM) was established in May 2008 to address the issue through community-based solutions that focus on collaboration, information-sharing and education.  The following organizations serve as partners in the coalition: Alberta College of Physicians and Surgeons, Alberta College of Pharmacists, Alberta Health Services, Health Canada (First Nations Inuit Health Branch – Alberta and Compliance Monitoring & Liaison Division), Safe Communities Secretariat, Edmonton Police Service, RCMP – Drugs & Organized Crime Awareness Service and freestone integrated communication ltd.

The initial steps focused on collecting recent data on the scope of the issue and providing input into a provincial and national model for a rapid assessment and monitoring of prescription drug misuse.  Two community identification projects were held to understand the perspectives on the issue of prescription drug misuse, and a website was created (www.prescriptiondrugmisuse.ca) to share information with partners and the public.

A key learning is that the issue of drug misuse is complex, far-reaching, and impacts people from all walks of life in all communities.  Like other drug misuse, the problem is not isolated in one geographical area, culture, gender or age group.  As such, a community-based approach is essential.  The coalition identified a need for a coordinated strategy to increase public awareness, improve the knowledge base, increase professional capacity, and effect policy changes.

Another key learning is that a good understanding of the issue and its root causes is critical, as unintended harm can occur without knowledge of “the bigger picture.”  For example, experience has shown that supply can not be reduced without an accompanying reduction in demand, as it will only increase the rate of pharmacy robberies and other theft.  A good understanding of the issue must be informed by available evidence (targeted research studies, population-based surveillance, system-level data already being collected) and the experience and knowledge of individuals, families, communities and professionals.

A number of challenges (medical, economical, social and systemic) were encountered by the coalition.  Alberta experiences all the different methods of diversion experienced by other provinces including doctor and pharmacy shopping.  Access to physicians and pain specialists also represents a barrier.  In addition, the potential for harm from prescription drugs is underestimated because of their legitimacy.

In terms of economic issues, the selling of prescription drugs is profitable and some people rely on the income generated from these sales.  Systemic issues also need to be addressed, including the limited ability to share information across providers and systems, and the confusion surrounding privacy issues.

Solutions that are emerging in Alberta to address the drug misuse problem include improving prescribing practices, enhancing communication between partners, promoting education and awareness, and improving services.  Solutions include the use of shorter dispensing intervals and guidelines for prescribing addictive medications, which may include assessment tools, descriptions of appropriate medications and alternative therapies, an emphasis on follow-up care and an outline of effective approaches for treating people with addictions. In terms of communication solutions, it is important to provide information on community resources to health professionals as well as clarifying what information can be shared within privacy legislation and procedures for investigating complaints with the College of Physicians and Surgeons of Alberta (CPSA).  A “360° circle of care” approach which focuses on patient safety, advocacy and accessibility to services would promote better patient, professional, and service communication, interaction and support. One of the main themes that emerged is that better communication and coordination of services would avoid relapse.  Increasing access to alternative treatments for pain management was also recommended.

Discipline-specific and cross-disciplinary education is critical in understanding the complex issues related to the misuse of pharmaceutical medication.  Public awareness campaigns on medication disposal were also noted as a key part of the solution. In conclusion, successful outcomes lie in creating a common understanding and shared responsibility for action across professional disciplines and within communities.  Encouraging stakeholders to look at their own spheres of influence to identify what they can do as individuals, professionals, and as part of communities is a critical part of the process.  It is also important to create opportunities and mechanisms for sharing information.  Finally, working together to identify the policy, social and environmental changes needed is imperative to addressing drug misuse.

Session IV: The Way Forward

Michel Perron, Chief Executive Officer of the Canadian Centre on Substance Abuse (CCSA) set the context for the last session of the Workshop and introduced the way forward discussion.  Following this, Reggie Caverson, consultant with CAVERSON Consulting, started connecting the dots and introduced a proposed framework to move forward on addressing pharmaceutical abuse on a national level.  This was followed by a facilitated discussion to confirm and adjust the proposed framework and to identify the types of activities and actions that the organizations present can undertake individually and collectively to begin to move forward.

4.1 Key Messages

Overview of Challenges

The issue of prescription narcotic misuse and abuse is a serious problem of growing proportions affecting many communities in Canada.  In recent years, law enforcement from Nova Scotia to British Columbia has seen a substantial increase in the amount of prescription drugs seized.  In some northern Aboriginal communities, according to various Aboriginal leaders, the problem has reached epidemic proportions.  Some of the unintended impacts of prescription narcotic misuse in society includes an increase in: unintentional overdose deaths; suicide; addiction; health care and emergency care costs; as well as theft, home invasions and armed robberies targeting pharmacies.

Various pathways have been identified as potential sources. For example, some individuals obtain prescription drugs from a legitimate prescriber such as a doctor or dentist, while others obtain them from a friend, relative and in some cases an illicit drug dealer.  Diversion happens in various ways, including; doctor shopping, fraud, prescription theft and forgery, residential and pharmacy robberies, and breaks in the manufacturing and supply chain management processes.  These drugs are very lucrative to sell and some even depend on the profits to supplement their income.

Prescription opioids present a unique health and policy challenge across Canada as they are critically important for severe and chronic pain treatment.  Because they are the primary drug covered under most medical plans for pain, they are easy to obtain, and since they come from legitimate sources, with relatively little risk there is often a perception that they are less serious than illicit drugs.

Inappropriate prescribing occurs for many reasons. First and foremost, there is a lack of education, training and awareness of physicians, particularly as it is related to the addictive qualities of prescribed narcotics.  As well, since there are no independent measures of pain, it is very difficult for physicians to determine the extent of a patient's pain, or whether they are simply seeking the drug for other reasons.  Physicians have very little time and ability to follow-up with a patient to ensure that medication is being used properly and there is a limited capacity to track and share information between physicians, pharmacists, law enforcement and other key stakeholders.

Provincial drug formularies also play a major role in a physician's decision to prescribe opioids for pain management.  Although these drugs have addictive qualities (withdrawal symptoms can appear after only 3 weeks of regular use at a prescribed dosage) and produce euphoric effects, they are prescribed because they are effective at treating severe pain and because other pain management options are limited in coverage (counseling and physiotherapy are rarely covered under provincial health plans).

Addiction issues are not simple to address, and some studies have identified a correlation between mental health and pain problems among those who become addicted.  The practice of self-medicating among those with undiagnosed mental health issues also warrants further consideration.  There remains a lack of accessible prevention, addiction and mental health treatment services across the country with significant variances in access between rural and urban areas.

Current Opportunities

Prescription narcotic misuse, abuse and diversion is an issue that touches many Canadians in many different ways and there has been increased attention to it both nationally and globally, which has made it politically compelling.  This greater attention has also led to an increasingly clear picture of a very complex situation.  There are existing networks with some capacity to help to address the problem that can be capitalized on; the federal National Anti-Drug Strategy (NADS) renewal also presents an opportunity.

Key Learnings and Emerging Solutions

Responding to the impact of drugs on the health and safety of communities is a complex and shared responsibility across various sectors.  Through experience, various stakeholders have found that scare tactics, hard-line strategies, one-time efforts and single-focus approaches do not work.  The misuse, abuse and diversion of prescribed narcotics needs concerted attention and a collective intervention strategy that focuses on reducing the volume of prescription opioids in the population and addresses drug misuse without undermining the availability and quality of pain management.  It is important to start connecting the dots between all relevant stakeholders, including: police agents, prevention specialists, emergency care, regional coroners, pain experts, addiction professionals, pharmacists, prescribers (dentists, physicians and surgeons), researchers, regulatory bodies, corrections officials, school boards, universities, community organizations and others.

One of the main lessons learned from strategies implemented in various parts of the country is that a comprehensive strategy needs to include prevention and education, treatment, policy/regulations and enforcement.  It needs to address the underlying issues around pain, addiction, crime and the social determinants of health.

Some of the underlying principles for a comprehensive strategy include:

• A balanced and comprehensive approach that builds on current strengths.
• Clear, realistic, measurable short-term and long-term goals based on the best evidence available.
• Collaborative leadership (from both the public safety and public health perspectives).
• Committed community partners.
• A sustained funding commitment.
• Research and evaluation.
• A federal and provincial mandate to move forward.

4.2 Suggested Key Themes from Facilitated Discussion

In this informal brainstorming session, participants were invited to share key insights, make suggestions and provide recommendations on how to move forward.  A number of key themes and suggestions emerged from the feedback obtained.  These are listed below.

Partnerships and Collaboration

• Recognize that a national, integrated and coordinated effort is required to address the issue.
• Build trust between partners by working on a few “quick win” projects together.
• Partner with enforcement, health, medical and pharmacy associations to collaborate on national efforts.
• Establish effective communication channels between law enforcement, pharmacists, physicians and other key stakeholders.
• Identify ways to overcome privacy legislation restrictions to allow the sharing of information between key partners.
• Communicate with users and those who are directly touched by prescription drug misuse to understand their realities and motivations and to determine appropriate measures to move forward on addressing the problem with community partners.

In addition, the Workshop participants recommended reaching out to and engaging with the following organizations:

• The Canadian Institutes of Health Research (CIHR)'s Drug Safety and Effectiveness Network (DSEN), to address gaps in information on the safety and effectiveness of pharmaceuticals.
• The Canadian Patient Safety Institute (CPSI), a not-for-profit organization that raises awareness and facilities the implementation of ideas and best practices on issues related to patient safety.
• The Canadian Health Care Anti-Fraud Association (CHCAFA), which helps prevent fraud in the Canadian health care environment.
• The College of Alberta Dental Assistants (CADA); the health regulatory body for the profession of dental assisting in the province of Alberta.
• Public drug plan managers, to see if there is an opportunity to provide funding for an educational program.
• The Public Health Agency of Canada (PHAC), as prescription drug misuse is a public health issue.
• Health insurance companies.

It will be important to identify other stakeholders that may have a vested interest in the issue and identify how they might help address misuse, abuse and diversion.

Education and Training

• Reduce the demand for prescribed narcotics by better informing consumers and others through public education and prevention about the associated risks.
• Develop an “expert evidence” course specific to prescription narcotics and offer this course country-wide.
• Consider the need to educate the judiciary on issues related to prescription drug misuse.
• Organize an initial meeting to determine police training requirements on prescription narcotic misuse, abuse and diversion, identify what resources are already available on this issue and establish mechanisms to share them.
• Education on pain management in a 4-year undergraduate nursing curriculum takes less than 20 hours.  Medical schools in Canada provide limited information and guidance for their students.  It is important to include education on pharmaceuticals, drug interactions, mental health and addiction.  The nursing and pharmacy school curriculum should also include information about the drugs themselves and best practices related to the use and dispensing of prescribed narcotics for acute and/or chronic pain.
• Promote the implementation of the “Canadian guideline for safe and effective use of opioids for chronic non-cancer pain.”
• Provide training for police officers on how to investigate cases related to prescription drug misuse; Share an existing DVD resource on prescription drug enforcement that specifically addresses issues on the street, provides guidance on what to look for and how to prosecute.
• Provide information for pharmacists on effective measures to safeguard pharmacies against theft and robbery.

Opportunities and Quick Wins

• Organize a national day to encourage Canadians to return unused prescription drugs from their medicine cabinet.
• Develop a “What's in your medicine cabinet?” pamphlet that is adapted to a Canadian context.
• Increase funding commitments for pain clinics.  There are currently up to 2 year waiting lists to access these clinics.  Pain care specialists stated that they are committed to participating in a program to help reduce health care fraud as their ultimate goal is to help those in pain.
• There is an opportunity to review funding models at the provincial and federal levels with the renewal of the Health Accord in 2014.

Engaging Youth and the School System

• Offer presentations to school assemblies or plan 6-8 hour course units to engage the school system.
• Monitor progress of programming already under development, including for unintended impacts (ie: introducing youth to prescription drugs).
• Identify ways to ensure schools engage in prevention and education activities.

Resources and Information

• Address the significant lack of patient and public understanding of prescription drug misuse through public awareness campaigns and informational websites.
• Develop a compendium of effective ready-made resources that can be shared with colleagues.
• Work to develop a national data repository and access to data in real-time.
• Coordinate efforts to conduct new research and standardize data collection to address the current gaps in knowledge.

Political Will

• Include pharmaceutical issues in the NADS renewal to address the significant harm being caused by the misuse, abuse and diversion of prescribed opioids.
• National organizations should identify prescription narcotic misuse as an organizational priority to help the issue gain enough attention and to get it in front of decision-makers (Ministers).
• Consider that different organizations (around the room) have complex and diverse mandates and it can be quite difficult for them to take on another priority or issue.

Best Practices

• Developing a cooperative agreement  for information-sharing between police, pharmacists, and doctors regarding diversion and the appropriate sharing of information regarding individual patients or others when diversion is suspected. 
• Doctors should use electronic prescriptions to reduce theft and forging of prescriptions.  The implementation of an electronic prescription monitoring program across the country should be considered (review research on efficacy of what model works best).
• Prescribers and pharmacists should ask for photo identification for health cards when prescribing and dispensing prescription opioids.
• Conduct a comparative legislative review to clarify what information can be shared within privacy legislation and outline procedures for investigating complaints.
• Practitioners need current, up-to-date information to help them determine whether or not dispensing a drug to a certain patient is appropriate.  New Canadian guidelines assists practitioners to direct them how to interpret the data.
• The use of shorter dispensing intervals and guidelines for prescribing addictive pharmaceuticals may have the potential to reduce inappropriate use, however more research is required.
• In terms of successful legislative measures, the United States has modified its controlled substances regulations to address the high volume of prescriptions by allowing practitioners to prescribe refills on specified dates.  This allows for fewer dosages to be dispensed at any given time and allows for the practitioner to follow-up with the patient and ensure the medication is being used properly. 
• Representatives from prescription monitoring programs from across the country should meet to share best practices and discuss interprovincial issues.  Information-sharing challenges can be addressed though Memorandums of Understanding (MOU).
• The attention paid to problematic substance use is inadequate, and the services devoted to addressing the associated risks and harms are also inadequately funded and coordinated.  Recommendations were made to strengthen the services and support offered to Canadians with substance use problems.  There is a need to close the gap between need and response.
• Increasing access to and funding for alternative treatments for pain..
• There must be a mechanism to share best practices between provinces.
• Pharmacy robberies may increase when the supply of diverted prescription drugs is cut off.  It is important to work with pharmacies on robbery prevention strategies, without impeding their ability to do business.
• Focus groups with key community stakeholders are an effective way to gain a better understanding of varying regional perspectives and potential responses on the issue.

Next Steps and Closing Remarks

Next Steps

At the end of the 2-day Workshop, the group committed to moving forward on this issue on a national level and agreed to the following next steps:

• Organize an initial meeting with all interested parties to begin to plan the way forward (CCSA will take the lead on this).
• Identify key stakeholder groups covering health, treatment and policy perspectives that will help move this forward in a national realm.
• Establish a collective plan and identify key action steps, building on key messages that emerged from the Workshop.
• Create a community of practice to share information and discuss immediate needs and opportunities.

Closing Remarks

Yves Leguerrier thanked participants for their attendance and made the closing remarks found below.

Once again, on behalf of Public Safety Canada, I would like to express our sincere thanks to all of you for taking the time out of your schedules to participate in this Workshop, organized by my group in the Serious & Organized Crime Division.

The discussions over the past two days will be reflected in a final report that will be distributed to all of you. We hope that this report will also serve as a valuable resource for Public Safety Canada and our federal partners as we move towards the possible renewal of Canada's National Anti-Drug Strategy.

Thank you once again to all our excellent presenters and to our host city of Vancouver, and I wish you all safe travels.

Appendix A: Participants List

Appendix B: Agenda

Agenda

Date modified:

2022-07-29