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November 15, 2017

HOUSE OF ASSEMBLY PROCEEDINGS

Vol. XLVIII No. 34

The

House met at 10 a.m.

MR. SPEAKER (Trimper):

Order, please!

Admit

strangers.

Orders of the Day

MR. SPEAKER:

The Government House Leader.

MR. A. PARSONS:

Mr. Speaker, I move, seconded

by the Minister of Natural Resources, for leave to introduce a bill entitled,

the Serious Incident Response Team Act, Bill 24, and I further move that the

bill be now read a first time.

MR. SPEAKER:

It is moved and seconded that

the hon. the Minister of Justice and Public Safety have leave to introduce a

bill entitled, Serious Incident Response Team Act, Bill 24, and that the said

bill be now read a first time.

Is it

the pleasure of the House to adopt the motion?

All

those in favour?

SOME HON. MEMBERS:

Aye.

MR. SPEAKER:

All those against?

This

motion is carried.

CLERK (Barnes):

A bill, Serious Incident

Response Team Act. (Bill 24)

MR. SPEAKER:

This bill has now been read a

first time.

When

shall the said bill be read a second time?

MR. A. PARSONS:

Tomorrow.

MR. SPEAKER:

Tomorrow.

motion, Bill 24 read a first time, ordered read a second time on tomorrow.

MR. SPEAKER:

The hon. the Government House

Leader.

MR. A. PARSONS:

Yes, Mr. Speaker, I call

Order 2, third reading of Bill 13.

MR. SPEAKER:

The hon. the Minister of

Justice and Public Safety.

MR. A. PARSONS:

Mr. Speaker, I move, seconded

by the Minister of Natural Resources, that Bill 13,

An Act To Amend The Highway

Traffic Act, be now read a third time.

MR. SPEAKER:

It is moved and seconded that

the said bill be now read a third time.

Is it

the pleasure of the House to adopt this motion?

All

those in favour?

SOME HON. MEMBERS:

Aye.

MR. SPEAKER:

All those against?

This

motion is carried.

CLERK:

A bill,

An Act To Amend The

Highway Traffic Act. (Bill 13)

MR. SPEAKER:

This bill is now read a third

time and it is ordered that the bill do pass and its title be as on the Order

Paper.

motion, a bill, “An Act To Amend The Highway Traffic Act,” read a third time,

ordered passed and its title be as on the Order Paper. (Bill 13)

MR. SPEAKER:

The hon. the Government House

Leader.

MR. A. PARSONS:

Mr. Speaker, I call Order 7,

second reading of Bill 25.

MR. SPEAKER:

The hon. the Minister of

Health and Community Services.

MR. HAGGIE:

Thank you very much, Mr.

Speaker.

I move,

seconded by the Minister of Justice and Public Safety, that Bill 25,

Prescription Monitoring Act, be now read a second time.

MR. SPEAKER:

It is moved and seconded that

Bill 25, entitled Prescription Monitoring Act, be now read a second time.

Motion,

second reading of a bill, “Prescription Monitoring Act.” (Bill 25)

MR. SPEAKER:

The hon. the Minister of

Health and Community Services.

SOME HON. MEMBERS:

Hear, hear!

MR. HAGGIE:

Thank you once again, Mr.

Speaker.

I'm

pleased to rise in this hon. House today – slightly sniffly after my flu shot

from yesterday – to open debate on Bill 25,

an act respecting monitoring of

prescriptions in this province. It comes as no surprise that this bill comes

here. We have had discussions around the issues surrounding opioid use and

diversion for some time now. It has been labelled in other jurisdictions as a

public health crisis.

Just to

set the tenure and the background, Canada has more prescriptions for opioids per

capita than any other country in the G7, and Newfoundland and Labrador,

unfortunately, is at the leading edge of those numbers, too. It is felt that a

problem around opioid addiction stems from the liberal use of opioids and also

now, potentially, diversion.

I would

emphasize from the get-go, however, that the intent of this bill, which is a

legal framework to address monitoring of what are designated under the act and

then under the regulations as monitored drugs. The principle aim of this act is

educational; it is not punitive.

A lot of

the discussions now – and I suspect in Committee – however, will veer towards

the punitive end of the spectrum simply because those, by their very nature, are

unusual in the course of prescribing behaviour and medical behaviour in general.

I think it's worth stating now: there are a vast majority of people in this

province, prescribers in this province and dispensers in this province, who act

in an entirely professional and totally responsible fashion. This, if you like,

education piece is aimed at making that practice even better.

For

those people whose behaviour is egregious – and it is a very small number, both

of dispensers, prescribers and patients. For those individuals, they have, up to

now, been exceptionally difficult to deal with in a timely and responsive

manner. This is the principle purpose of this bill.

You can

go back through the department for maybe 10 years and find examples of

individuals who have been a source of worry, for whom there has been no simple

or straightforward approach to managing the problem. They have been managed

ineffectively, where they have been managed at all, and have often figured

prominently in the news, not once, but on multiple occasions before their

activities had finally been curtailed. This bill is to provide a legal framework

to help manage that very small group but, again, it's principal aim is to

educate and inform to improve clinical practice.

This

bill provides that legal framework to implement a Prescription Monitoring

Program in this province. The function of the program is going to monitor,

analyze and report information related to the prescribing and dispensing of

monitored drugs. Initially, the only and first category of drugs that will be

monitored – and this will be developed in regulation and stipulated there. The

first category and the only category will be that of opioids, which are

currently our pressing public health prescription challenge.

However,

Mr. Speaker, the bill is worded so broadly that additional drugs can be added in

the future. Benzodiazepines are another category of drug which would be worthy

of monitoring for a public safety point of view. Those numbers, however, and

their impact is smaller and less lethal currently than opioids.

We heard

just this week, however, and last, in data provided by OECD and CIHI around

category of drugs which are of significant public health concern but over a much

longer term. That, Mr. Speaker, is the use or inappropriate use of antibiotics.

Again,

to put that in perspective, this province has 33 per cent more prescriptions per

capita for antibiotics than the next leading jurisdiction in Canada. We are way

over the national average in use of a category of drugs that will actually, if

it continues, jeopardize safe health care for a whole variety of conditions.

Obviously, the impact on life and limb in the short term is nothing like that of

opioids, but in terms of a public health, a problem on a global scale, I would

suggest, antibiotics have just as big a potential to actually kill indirectly by

being useless on those occasions when we need them most. This bill and the

regulations under it that will be crafted would allow for monitoring of

antibiotic prescriptions, for example, should the need arise.

For the

moment, however, I will go back to the focus of the program, which is

principally opioids. For those of you who don't have a background in pharmacy or

prescribing, opioids are basically derivatives of opium. They are categories of

drugs such as morphine and its derivatives, which are well used and have a

well-respected and established place in clinical practice, but also other drugs

such as heroin which, in this country, anyway, is not recognized largely as a

prescription drug, although other jurisdictions do allow its prescription. There

are some programs in Vancouver, for example, where this can be obtained legally

through prescription.

They

are, and have been for a long time, an important and legitimate class of drugs

used in pain management and have been essential in such areas as the acute

surgical situation, for example, with which I was much more familiar, but also

in cancer care and palliative care.

The

national trends have shown an increase in opioid prescriptions, and this is of

concern because in actual fact they are drugs of habituation and addiction,

physical and psychological dependence. Classically, we were taught, when I was a

resident, that this would be something that happened in a very small percentage

and only after a prolonged exposure. But there is now evidence, for example,

that even those people who receive a prescription for post-operative pain

relief, those people whose prescriptions last six days or longer have fully four

times the rate of addiction than those people who have five days or less, and

that is a real alarm bell.

I have

to say, Mr. Speaker, that the medical profession and prescribers in general were

actively misled by companies such as Purdue Pharma, the manufacturers of

OxyContin, to the point where I think, personally, they bear no small

responsibility for what is actually a global catastrophe. And the most worrying

thing from a moral and ethical point of view is that they may have exhausted

their good will in North America, but they're now turning their sights on India

and Brazil where the populations are huge and the regulations minimal.

So, I

think, again, I digress slightly, but I hope no one will argue the issue of

relevance on this particular point. The most recent statistics indicate the

number of people referred for treatment for opioid dependency in Newfoundland

and Labrador have jumped by 600 per cent in seven years. They have gone from 73

people in the year 2007 to 2008 to 443 in the period '14-'15.

These

referrals resulted in a variety of treatment options ranging from counselling, a

dependency treatment using drugs such as methadone, which has been the mainstay

– we've now moved toward Suboxone – and there are other injectable medications

of what is called a depot preparation which are long acting, which are showing

some potential here. We're keeping an eye on those as options for the future.

The

Prescription Monitoring Program, however, is not intended – not intended – to

prevent the use of monitored drugs for legitimate medical purposes. There are

many reasons why an opioid is the most appropriate treatment for a patient's

condition and this program is not meant to deter prescribers from making an

informed clinical decision to make that prescription. It is hopefully going to

be a tool to educate them so their decision becomes more informed.

The

primary goal, apart from that, is to ensure that when an opioid is prescribed

both the prescribers and dispensers have up-to-date and accurate patient

information when they make that decision and when they write that prescription.

In a sense, this is actually the earliest form of a decision support tool that

we are mandating and building into the system.

The

trend of opioid use, diversion of opioids, overdoses and death nationally and in

Newfoundland and Labrador is and continues to be a growing concern. Numbers in

British Columbia, which is kind of the leading edge of this way, show that

already this year there have been over 1,000 deaths from opioid poisoning. I

don't think these people have overdosed; I think they've been poisoned by

additives to what that they thought were legitimate street drugs. Their heroin

or their cocaine has been laced with a poison called fentanyl or carfentanil or

one its derivatives, which is lethal in minute doses.

In 2016,

there were 2,816 apparent opioid-related deaths in Canada. In Newfoundland and

Labrador, we had 57 hospital admissions involving opioid poisonings and 16

apparent opioid-related deaths. Of interest, on a harm-reduction level, the

naloxone program, to which I have alluded on many occasions, has actually been

used at least as often as that with, good results; i.e., people who would

otherwise have perished are alive because of that program. I will highlight the

importance of that program a bit later on in this legislation because it's part

of a piece of a bigger jigsaw.

The

bottom line from those statistics is essentially these are extremely concerning.

In November of 2016, I joined with my federal provincial and territorial

counterparts to release a joint statement of action to address the opioid crisis

in response to some of the background I've just provided. At that same time, I

also announced the province's Opioid Action Plan in response to that situation.

One of

those action items, there were education pieces, there were some legislation

we've already referred to, Bill 55, from a previous session where we have

options for secure withdrawal management and also harm reduction strategies

again around the naloxone kits and needle exchanges. One of the action items

identified in November of 2016 was the introduction and implementation of a

Prescription Monitoring Program. This bill, and my standing here in this hon.

House today, is the culmination of that process.

The

program builds on other measures that I've referenced. Education; we have a new

mandatory safe prescribing course for all newly licensed physicians that went

live on the 1st of January. We are the first province in Canada to have done

that. Others are now following suit. We funded that through Memorial University

and the College of Physicians and Surgeons. Early reports show that in other

jurisdictions elsewhere in the world where they've tried this, it has had a

beneficial effect.

We had

Bill 55 passed,

An Act Respecting Secure Withdrawal Management for Young

Persons. We have a public awareness and education program on opioids and we've

also, as I referenced, gone into harm reduction manoeuvers around naloxone

take-home kits. As I say, we've used anywhere north of 16 of these. It's very

difficult to track sometimes the usage, but what reports we have on those 16

would suggest that they have reversed a potentially fatal situation.

We've

had naloxone pop-up tents which were initially collaboration between government,

Eastern Health and the City of St. John's. I'd like to shout out to my colleague

for Virginia Waters – Pleasantville who was a key link between our department

and them at the time. Festivals across the province have also seized on the

opportunity. I would encourage those folk who are planning for next year's

events to contact their local RHA. All we need is a space and a tent and we'll

do the rest.

To get

on to the program itself, these monitoring programs are being used in all

jurisdictions across the country, with the exception of Quebec, with the intent

of helping prescribers and dispensers make informed decisions about who requires

opioids and how and what that form should take.

Again,

for emphasis, the purpose of the program is education. It is to help prescribers

and dispensers make the most informed choice at the time when they feel that

prescription is necessary. It's not an intent to police professionals. It's

rather to give them access to information in a timely way about their patients

at the time the drug is either prescribed, or in the case of dispensers, at the

time it is actually dispensed with reference to the monitored drugs.

This

program will assist those professionals to make better quality decisions, but it

also will allow them to look and potentially identify folk who actually have

opioid dependence simply on the basis of their prescription pattern. That, in

turn, will allow them at least to be offered appropriate services and a

discussion to take place about how they wish to deal with what could be a

dependency or addiction. One of our challenges is sometimes actually identifying

people in that situation. That can then lead on to formal programming and help

them to manage and recover from their addiction.

The

foundation upon which this program is built is the Pharmacy Network. There was

reference made in this House to that network on previous occasions. It finally

went live in the spring of this year and was a success. We have anecdotal

preliminary information already from NLCHI that there has been a reduction in

adverse drug events. Unrelated to opioids, there's been a reduction in duplicate

prescriptions and there's a reduction in prescription errors as well.

Indeed,

going back to the first two individuals to connect to the Pharmacy Network

before it became mandatory, they in actual fact, the day they were connected,

identified an issue with potential double doctoring of opioid prescriptions. It

works, Mr. Speaker, in short.

In turn,

the Pharmacy Network itself is a component of an initiative around the

province-wide electronic health record, which we commonly refer to as HEALTHe

NL. The Pharmacy Network is comprised of a real-time database of medications. So

when a patient goes in to receive a prescription and get the drug dispensed,

that fact is entered into the database as it happens, live from all of the

province's pharmacies that are outpatient pharmacies.

spring, we have connected all 201 of them to the system. What the HEALTHe NL

viewer does is simply a front end, at no cost to the prescriber, which will

allow them to access that profile and close the loop, so that not only does the

pharmacist see the patient's dispensing history, but at the time the

prescription is written, a prescriber can look at the viewer securely, bring up

the patient's medication history – with respect to any drug over any period of

time that has been filled – and have that information at the time the

prescription is written.

It's

that complete medication profile, whether they filled a prescription in St.

John's and are now getting another one filled in Gander or Grand Falls or vice

versa, that's real time, it's live and it's current. That is the key, to have

that information in the hands of the prescriber at the time the prescription is

written itself.

Ideally,

with the fullness of time, the prescription itself wouldn't be written any more.

It would be composed, if you like, electronically and sent automatically to a

pharmacy of the patient's choice. Once more prescribers get on to the electronic

health record, then that will become a reality. This in the meantime is a hybrid

which has worked in other jurisdictions. I'm referencing British Columbia here,

which gets around the requirement and the onus to force change on physicians or

prescribers when there may be a cost incurred. They can plan this in a more

leisurely way.

Although

at some point, Mr. Speaker, the facts of the case are that good, quality,

primary care requires an EHR in a team environment. So with the fullness of

time, I would suggest that patients may well be at a disadvantage in those

practices that are so low and don't have an EHR. That is, however, outside the

remit of this act.

British Columbia – we are not reinventing the wheel here. In British Columbia,

what they did, just like us, we have tamper-proof prescription pads. These are

specially printed documents unique to a physician or made so by the way they

have to be filled in. These exist already and are used for what are called

control drugs, which are legally defined in a different way.

That

mechanism will continue, but we will likely modify. This will be prescribed

under regulations, so it's not part of the act. We just have an explanation here

for workflow.

physician or a nurse practitioner, or a midwife – when we get more than the one

we have at the moment practicing – and dentists will annotate in a way to be

prescribed that they have viewed the healthy viewer at the time the prescription

is written and are satisfied that there are no issues with issuing this opioid

prescription. It will be signed, maybe timed and dated, and the prescriber's

number will be affixed to that signature. Essentially, they're using their

licence and their professional standing to certify that in their professional

view there's nothing untoward about issuing this prescription.

I go

into that detail simply to enlighten folk who may not have the background of

others as to how prescriptions actually would be written in the system. This is

a hybrid, but it's worked well in British Columbia.

So to

speak a little bit more to the nuts and bolts of the bill. It provides the

necessary legal authority for us to actually operate the program. It grants

powers to and imposes duties on myself, the Minister of Health and Community

Services. It also has those same impositions and requirements on dispensers,

prescribers, regulatory authorities and also patients, because they have a role

to play in this, too.

Again,

the object of the program is around education, support and assistance to those

groups to avoid misuse and potential abuse of drugs that are designated, under

regulation, as monitored drugs. These monitored drugs will be defined, and as

I've already indicated, we're starting with opioids initially and the

regulations for that will be in place prior to the implementation of the

program.

The bill

does specify it's the minister who's responsible for the program itself.

However, the bill also does permit delegation of powers and duties by the

minister to an entity or person. In conjunction with discussions with the

Information and Privacy Commissioner, that delegation was felt to be required

that it be delegated to someone who is also designated as a custodian under the

Personal Health Information Act . That

was a recommendation from the Privacy Commissioner, and it addressed a lot of

his concerns about potential loopholes or gaps in safeguarding what is sensitive

personal information.

It also

allows us to store complete information. By having the custodian designated

under fear, we can store everything that is relevant to the patient; everything

that is stored in that is secure and protected in a way that other legislation

may not be as stringent. So it holds us to a high standard.

The

intention also is that Newfoundland and Labrador Centre for Health Information

would be the delegate to administer this program. The logic behind that fits in

with other announcements we've made around streamlining of IT and clinical

records services electronically in the province. Essentially, the centre

currently houses several provincial electronic databases and principally the

Pharmacy Network.

As I've

already mentioned, the Pharmacy Network is the foundation block without which

this program would not be feasible, and that had to be up and running. Just to

remind folk, that happened 1st of July, just past. So we've really tried not to

drag our feet with this.

We've

had the Pharmacy Network up and running and I might say with minimal fuss. We

have had some issues with one or two pharmacies, but in actual fact on closer

examination that was an issue with their Internet service provider and not with

the technology or the centre itself. The centre would then house this

information and would generate reports which would be descriptive and could be

sent to prescribers and dispensers and also allow analysis about patterns of use

and potential sources in the case of opioids of diversion.

As I've

mentioned, at the time of writing a prescriber would be required under the act

to check the medication profile and to sign to that effect. The profile, I can't

stress, is key. A real time, up-to-date profile is key to the safe and reliable

functioning of this.

Equally,

the dispenser currently already has to check in the Pharmacy Network but there

will be a specific onus on them in the issue of monitored drugs for them to do

that. Their systems are flexible enough that this could be done electronically

and wouldn't require a paper process.

The

regulatory authorities are also involved in this. Again, this is where you start

to stray into that grey area of what is acceptable professional practice, what

is questionable and what is downright egregious and possibly even criminal.

There

will be a mechanism stipulated in regulation whereby once certain thresholds are

passed, that information would be conveyed to them. Should they take action or

have already taken action where a particular prescriber's licence has been

constrained or abridged in any way, that information would have to be fed in to

the system so that we could then identify any situations where someone who was

not allowed by their professional regulatory body to go near opioids or

benzodiazepines in the future, were they to issue a prescription for that, this

would be flagged and of itself would constitute behaviour that would require

notification.

understand that the decision around prescribing any drug is one related to the

clinical autonomy of the prescriber at the time. It's not our intent to tinker

or abridge that autonomy in any way, but we also recognize the prescriber's

ability to do that role and fulfill that role properly is kind of dependent on

the right information being fed to them by patients. That's why within the act

there's a specific onus on patients, on individuals seeking prescriptions, to be

honest and truthful as to the reasons for them seeking that.

If that

information that they provide is inaccurate, there will actually be consequences

potentially for the individual. There is wording in the act to cover the event

where you have someone who goes to mislead a prescriber and it is an offence. It

states that the patient is not knowingly to provide false or misleading

information at the time a prescription is sought.

Once the

data is housed and stored through the Pharmacy Network, there exists an ability

to flag unusual activity, the most obvious being where a person visits multiple

prescribers in the same day or multiple dispensers to obtain monitored drugs. As

part of the operation of this program, when that flag is triggered, we need a

mechanism to actually act upon it. That's part of the framework that doesn't

exist at the moment.

Officials would have to reach out to prescribers and dispensers to seek

clarification with respect to a prescription. The bill provides authority for

the minister or a delegate to request information where that's reasonably

necessary to achieve the objectives of the program.

Where

there are reasonable grounds – and some of these will be in terms of thresholds

and triggers that will be worked through in the regulation – the bill authorizes

the sharing of information between prescribers, dispensers, the regulating

authorities and if need be, law enforcement. It allows the safe, protected

information to be released in a controlled way when certain thresholds are

passed to either a regulatory authority or maybe to a regulatory authority and

law enforcement, or in the situation of what's been colloquially termed doctor

shopping, maybe to law enforcement directly.

The bill

authorizes that sharing and allows for the management of more egregious

circumstances. Again, I go back to my opening comment. This is not a punitive

bill, but there has to be a stick along with the educational carrot. Part of the

problem we're trying to deal with is not the behaviour of 99 per cent of people;

it's the behaviour of 1 per cent of the people. Those percentages may be off a

little bit, it could be 95 and 5 per cent, but the facts of the case are the

vast majority of people involved in opioids are involved for perfectly

legitimate, entirely appropriate reasons.

Bill 25

also contains an inspection regime whereby the minister can appoint an

individual, or person, who will be a custodian under PHIA or an employee of a

custodian. The reasons for that, again, relate to concerns the Privacy

Commissioner had about who should have access to what in the way of sensitive

information.

It's

important to note again – and I can't repeat this often enough because there's

some fear mongering going on about how this is a punitive exercise, but the

object of this program is to educate and assist. It's not meant to go out and be

a big stick.

It is

anticipated that in the issue of an unclear indication for opioids, or an

unusual prescription outside the prescribers normal profile, for example, that

the vast majority of people would comply with a request for information. We do

this regularly for physicians through MCP for their financial billings. There's

an audit process and there's very little issue for the vast majority of

individuals.

But

again, we're moving away from the behaviour of the reasonable individual into

territory that is at least gray and possibly criminal. So in order to address

that we do actually have to have the option of additional powers to address

issues of non-compliance. This, again, is for that very small percentage of

individuals, prescribers, dispensers, whose behaviour is well outside the norm

for their peer.

So as

part of the implementation process, the bill permits the establishment of an

advisory committee to address, if you like, this clinical audit function. You

don't have to have it, but the bill states quite clearly, should you exercise

that option, it has to have at least one prescriber and one dispenser on that

committee. The reason it's worded like that is to reflect potential flexibility,

depending on who the prescriber might be on an occasion, whether it's a

physician or a midwife or who the dispenser might be.

As I

say, while setting up the committee is discretionary – we don't need to create

committees we don't need and have standing committees all the time – when you do

the act, not the regulations, the act requires that there be at least one

dispenser and one prescriber on that committee.

The

function of that is to entrench appropriate clinical expertise in decisions that

essentially touch on clinical autonomy or clinical decisions. There's no point

in having a politician, a civil servant or an accountant decide on that

approach.

The

purpose of this committee is to provide advice and recommendations on any

matters that might be referred to them through the program. They're there to

educate the administrators of the program and the minister, if need be, on

what's gone on and whether this request or whether this prescription or

dispensing activity was clinically entirely reasonable.

In the

first instance, Mr. Speaker, it's the intent of Health and Community Services to

have two committees. One of these will be made up of representatives from

regulatory bodies, law enforcement, community partners and government

departments that have an interest in opioid use and diversion. During the

development of the program, we actually had a committee of such stakeholders who

provided advice and guidance on the development of the program and the framing

of this legislation. It would seem sensible to continue this committee and morph

it into that advisory committee.

The

second committee is the one I've referenced about clinical expertise, but in a

slightly different way in the sense of reports, what you do with these

educational pieces, how should they be crafted so that the end-user can get the

best benefit from them. There have been a variety of strawmen, if you like, for

prescribing and practice profiles that have been used over the time. I can go

back to my time with the NLMA when we did that with billing activities for

fee-for-service physicians. I know currently choosing wisely – and Dr. Parfrey

through the university is looking at specific activities within the realm of

clinical practice and has developed a series of indicators.

The most

common is simply a kind of box-and-whisker plot where you have an average for

your group and a range of, if you like, normal activity and then a little line

as to where you, as your individual practitioner, fall. That group could be

defined as being geographical. For example, before I retired it could have been

general surgeons in Central or off the Avalon, and it could also be described in

terms of specialists in general or general surgeons of the province and that

would be a different comparator.

Those

actually shift because different people have different practice profiles. There

are at least three or four, for example, family physicians whose principal area

of clinical activity are outside of family medicine in addictions and mental

health. They're prescribing profile, particularly for things like methadone,

will be completely different than a GP whose main focus is care of the elderly

and, in turn, that would be completely different from someone whose main

emphasis is on palliative care. You have to compare apples and apples, not

apples and anything else you happen to have.

The

clinical expertise on that committee will help determine how those reports

should be crafted. The proclamation of the bill we have proposed as the 1st of

January 2018. The regulations are well underway. There's one

section of the bill

that we have suggested should be delayed and we've suggested it be delayed until

June 30, 2018, and that's

section 7 which specifically relates to the

requirements for prescribers to have the HEALTHe NL viewer. Again, this is not

an electronic health record as such; it is simply a portal to the Pharmacy

Network to see who's written what and what patient has picked up which drug.

It is at

no cost to the prescriber that doesn't already have it as part of their EMR or

EHR. It is something you can put on a CD. They will simply require a username

and a password, which will be sent to them by NLCHI, to make sure the access

they get is authorized. That's the bare bones of it. How that will be

operationalized and the time to actually do that is why we're looking at June

30, 2018 for that final piece.

The

other piece of that is that NLCHI has to work with the regional health

authorities to actually push that software out to all their PCs and terminals

across their facilities. Again, not a lengthy process, but there's a change

management piece in there in that people have to get comfortable with using it.

It's not difficult. Even I, as a surgeon, could manage to use it. As they say:

It ain't brain surgery. I think, in fairness, it's a process that's analogous to

what went on with hooking pharmacies into the Pharmacy Network.

We have

spent a lot of time in the department consulting with the stakeholders I've

alluded to: provincial health care regulatory bodies, law enforcement, community

groups and professional associations. Their input has all been put in the

blender, if you like, and is manifest in this bill.

We've

also looked at other jurisdictions. We have really taken a leaf out of BC's

book, and I make no apologies for that. They have led the way, unfortunately,

because of a variety of social, cultural and geographic factors whereby the

opioid issue has become their problem first and slowly spread east.

Our

issue is it's kind of jumped a little bit because once it got into Alberta with

our connections and family connections and work connections, that has come back

a bit quicker than it would if it travelled by road.

The

bottom line from all these groups – the feedback we've received has been

predominately positive. There are always little nuances about whether or not

there should be this facet or that facet put in the bill, but I think there's a

general acknowledgement – well, I know there's a general acknowledgement out

there that this piece of legislation in principle is crucial. There's also a

groundswell of support for the bill as it is currently written.

I notice

the time is ticking down. I just have a few concluding remarks. Again, and I

make no apologies for repeating this,

section 3 quite clearly states that the

objective of the program is to educate, assist and support the use of this

technology and this program for prescribers and dispensers with relation to

drugs that are monitored. In the first instance, that will be opioids. The

reason for that I highlighted in my opening remarks. It is not in any way meant

to be punitive. That might sound paradoxical given the fact that there are

significant chunks of the act which refer to inspectors and quasi-judicial and

judicial approaches to what some would view as a clinical activity.

I hope

my remarks have framed that in a way that makes that understandable. It is the

vast majority of prescribers and dispensers in this province who do an excellent

job, competent job, and look to be educated and fine tune their practice using

this information. There are, however, small groups or small numbers of

individuals, both prescribers, dispensers and members of the public who misuse

opioid prescriptions, either for personal reasons in terms of managing their own

addiction, for which we now have a tool to identify them and help them, or for

criminal activities, which I cannot condone nor will I.

So for

those individuals, it is important that we have a mechanism whereby we can deal

with them appropriately. The first issue is around identifying and building and

verifying your case. That's where the inspection piece comes in. That's where

the role of enforcing compliance with request for information becomes crucial.

If you go back over the last 15 years, for those individuals whose behaviour has

been sanctioned because it was egregious, it took 10 years in some cases to

bring these people to task and to be able to successfully terminate their

activities.

Again,

if you go into detail on some of those on an individual level, this was not the

first time these individuals have been brought to the attention, but because a

framework like this did not exist in terms of data collection and because there

was no rigorous mechanism by which they could be held to account, they got away

with it, or they got back to it somehow. This is an attempt to close that

loophole, because a small number of people with criminal intent actually have a

huge impact on the general health of the population.

You

don't want someone diverting significant quantities of opioids into small

communities around this province, or any community, no matter what the size.

Unfortunately, there are suggestions that that is happening. This will find

those individuals and hold them to task. The bulk of the people who will use

this are responsible, dedicated, committed individuals who simply want to do

their own job better, and that was very much the message we heard from the

clinicians I've spoken to about the intent of this bill. So this is about

building confidence in that group. It's also about building confidence in the

general public so that they realize we have seen a problem and we have acted to

manage that.

There

are harm reduction issues that will flow from this. This is not going to make

our job any easier on the harm reduction front. If you look at what's happened

in other jurisdictions, there has been a move for some people with particular

challenges to more illegal activities. So in terms of the addicts options, it

has tended to push them towards the street. This is why last year we had such an

emphasis on harm reduction. We have not stopped with harm reduction and we have

other measures that we are continuing to discuss, both in the province and with

our federal counterparts.

Really

and honestly, we cannot allow one of these drawbacks to jeopardize what is a

sound, popular, well-supported piece of legislation. So, yes, it's not perfect

in the sense that it will have a consequence, but in terms of the problem it is

designed to look at, this, I would suggest, is a comprehensive and clear way of

dealing with the issues I've highlighted.

builds on a successful program. It builds on the Pharmacy Network, which once

the change has been completed, as I say, with the exception of a couple of

businesses who had challenges which then turned out to be related to Internet

service provider and router, not the program itself, we have had really very

little in the way of any issues. It's already anecdotally started to bring down

prescription errors, duplicate prescriptions, and reduced the number of adverse

drug events. We will hopefully have some comprehensive statistics to report,

probably at the end of its first full year of operation.

recognize that prescription drug misuse, particularly opioids, is a real issue.

This is a start that's focused on that issue. To get this done, it's not just

going to be a matter of passing a piece of legislation in the House and writing

some regulations. To address the societal impact of opioid misuse and addiction

– and drug addiction in general is not something government can do by itself –

we need front-line health care workers who are dedicated and want to see

progress. It also needs the public to recognize several things.

If I had

one sort of slightly off-track message here, the recognition that addictions is

actually a disease and not a lifestyle choice would probably be the

single-biggest societal change that I would welcome in this province. I cannot

do that by myself. People of influence, thought leaders, education are all part

and parcel of that.

Without

that mind switch, we are going to find people who will naysay this on the

grounds that somehow we are supporting unacceptable lifestyles. I'll put that

out there now in case anyone wants, either here or in TV land, to bring that

argument up. Bring it on. I'll talk to you about it because you're wrong – you

are wrong.

acknowledge that the program is taking some time to develop. You can have it

quick or you can have it right. This is a compromise. I suspect some people will

find issue with some of it. I think it's more right than quick. Having said

that, the Pharmacy Network only went live 1st of July this year. That is not six

months, and here we are with the Prescription Monitoring Program bill as

advertised; action not planning, not a strategy of strategies, but some concrete

and tangible developments.

The

commitment of the people who have been involved in this, I think, really has to

be commended. I've already alluded to that in another place, but I think I'd

like to read into Hansard the

fact that the individuals here, the RNC, the RCMP, the community groups on the

Burin and in other areas, and Ruby who actually made the trip in from the Burin

today –

AN HON. MEMBER:

Marystown.

MR. HAGGIE:

Yeah, sorry. Thank you. I'm fumbling for that one.

These folk have committed enormous effort and enormous time

to help make this possible. I think it doesn't do any harm at all to repeat that

whenever possible.

Mr.

Speaker, I'm going to abridge my time a little bit. I'm simply going to say I

commend this bill to the House. I look forward to hearing comments from the

other side of the House. I look forward to handling any questions in Committee.

I really think this is another milestone in our management of what is a

significant public health issue, and I look to the support of the House for it.

Thank

you very much.

SOME HON. MEMBERS:

Hear, hear!

MR. SPEAKER:

The hon. the Member for

Conception Bay East – Bell Island.

MR. BRAZIL:

Thank you, Mr. Speaker.

It's

indeed an honour to stand in this House on this Wednesday morning and speak to

Bill 25, Prescription Monitoring Act .

I have to agree with the minister here. There are a number of key points that

he's outlined here that I personally wholeheartedly support, but particularly

the first one that in isolation none of us, no matter what agency you are, no

matter what professional you are, no matter how much of a concerned citizen you

are or if you're a parent or if you're a user or recovering addict, that we can

solve this issue alone. There has to be a holistic approach to addressing the

opioid epidemic that we have here, but particularly the impact that it's having

on our society.

We see

it in every community. I'm glad the minister acknowledged, too, that there are

grassroots agencies and organizations that are made up of citizens who are

coming forward to lend their support to addressing this issue. There's no doubt

we need legislation that helps move it to the next level, that helps us identify

exactly what are the main issues, how do we monitor what's happening, how do we

ensure that everybody involved in this are on the same page. There are

components and approaches that can be done that will make an even flow to the

whole process.

As the

minister had talked about, the impact that opioids have had in our society and

in this country and around the world, and the devastating impact it's had on

families, but particularly individuals. I've had personal experience in my own

community with agencies and organizations who have just recently been

established because of the loss of young men and women from overdoses and their

long battle with their commitments to the opioids.

As the

minister had noted, too, we need to get to understanding the philosophy that

this is a disease versus just a standard lifestyle. Because there is always some

adversity to sectors in society who don't normally follow that trend. It's easy

to point blame versus actually saying we have a responsibility and we have a

stake in this. We need to be able to do that and address it in a manner that

solves the issue here, but particularly engages all of our own segments in our

society. Looking at how we address the opioid issue here is no doubt very

important to our society.

Having

legislation that puts it at a higher level and includes the key stakeholders is

very important, but I first again want to spend a few minutes about the impact

that it's having. I think that our listeners who may not be tuned in to the

issues of opioids and may not have had experienced that in their community, in

their neighbourhood or particularly in their family would understand the impact

that its having on our society. Not only the ultimate loss of life – that's the

ultimate impact that it would have on these individuals and their families – but

it's the loss of productivity.

It's in

some cases, unfortunately, the lifestyle that it leads these people who are

addicted to the opioids from a criminal point of view, from a lack of education,

from a breakdown in the family unit to not being productive citizens, to not

being engaged in our society. That has a dramatic effect on what we do in

Newfoundland and Labrador.

There's

no doubt any piece of legislation that comes to this House and gets debated, the

intent is always to improve a program, a service, to address a particular need,

to in some way, shape or form find a better approach to including our citizens

and ensuring their quality of life is better. To address that, particularly if

it's a grave issue that people are facing like addictions, particularly around

opioids, we need to have legislation that is balanced, respects the individuals

who are involved, respects privacy, but finds a better way to ensure that the

whole access and the flow is the continuum.

There

are going to be different degrees of interventions, different degrees of

monitoring, different degrees of partnering to address this particular issue.

It's not just the prescribers. It's not just the dispensers. This is a bigger

issue here. I'm glad the minister ended his address here on that note, that

there's a higher level of collaboration here that has to take place if we're to

address this. What this legislation will do, it will frame it in a legal manner

that instructs and guides agencies, organizations, government departments,

stakeholders to ensure that the process being followed is in line with us being

able to find a solution and address the particular needs.

One of

the particular needs has been noted, and it's been discussed by organizations,

users, professionals in the field, is the overprescribing. Probably the bigger

underlining issue is: Why are we overprescribing? Is it our particular

lifestyles? Is it our physical makeup? Is it it's easier to address – is it that

we have so much faith that we as Newfoundlanders and Labradorians are that much

tougher that we don't get addicted to things as easy in other issues?

That's

not necessarily the truth in the world. We always think we're indestructible,

but in our society, as Newfoundlanders and Labradorians, we're susceptible to

any other issue in life that may be physically detrimental or, in this case,

medically detrimental, which has a total impact on your holistic life here and

that's the addictions to opioids.

Opioids

are prescribed for various multitudes of medical interventions. As we know, 95

to 99.9 per cent of the population can use that opioid to address whatever

particular ailment that's relevant to without any issues around long-term

addictions, without any issues around it totally interfering with their life. As

a matter of fact, in a lot of cases it helps them get back to a normal standard

of their everyday activities and get to the recovery.

Unfortunately, there's a group, for a number of reasons, that they become

addicted to it. That addiction becomes a disease. How we address that is very

important because it has an impact on what the rest of us do here in society.

What

we're going to be talking about here and what I do like about this part of the

legislation – and the key component here: It's meant to educate, support and

assist. They are philosophies that we try to embed in everything we do here, if

it's around education, if it's around inclusion, if it's around health care, if

it's around democracy. It's about how we educate people. It's how we support and

how we assist. We need to find the perfect balance that includes all of those

three components so that we know at the end of the day what we've put in play

will be successful.

There's

no doubt there's no magic wand, there's no quick fix, there's no let's nod and

it's all taken care of. That doesn't happen in any society. It definitely

doesn't happen when you've got something that's an addictive process and it's

disease related. That's what we're dealing with here. It becomes a holistic

approach to how we address issues around that.

What

we're creating here is the Prescription Monitoring Program. In a previous life a

number of years ago, I had the privilege of working with some professionals in

this field about the concept of that. The issue they had was there was no

ability to really monitor how often somebody who was abusing these or were so

reliant on them or the criminal element were having access to it.

didn't have a proper monitoring process to know what was happening in dispensing

and what was happening in prescribing in one area wasn't happening a day later

or two hours later or a week later for that same individual because the intent

of the use of it may not have been why it was prescribed. That becomes the

dilemma.

Obviously, as a professional who would be in that field, they must shake their

head sometimes in disbelief. Because they go in with the right intention, the

right diagnosis, the intent of saying here, this will improve your recovery;

this will help you get to the next stage so you can be more productive and more

engaged in whatever activity you're doing. This is to address, in a temporary

manner, the particular aliment you have. It's unfortunate, and I can't even

imagine as a professional, a prescriber, a doctor, a physician, what that means

when they come back and see their patient further down the road and see what

that's led to, the addiction issue and the impact that's had on their lives.

I see it

talking to some of my pharmacist friends, who've seen a young man or a young

woman come in, initially having to get a prescription for a particular pain

killer, a particular opioid, and then six months later see the downward spiral

and the impact that's had because now they're addicted to it. It's become a

disease to them. The process of getting them away from that and the supports

that are necessary sometimes are not always in play. That has a devastating

effect on those who prescribe it.

At the

end of the day, I've talked to many who've said I come in and sometimes I shake

them and want to say you're not getting this prescription; but, at the same

time, they know they're reliant on it. They need to have it. This is their

day-to-day activity. So professionals acknowledge the fact there has to be

another way that we can do this. The best way, no doubt, is preventative

measures.

I see

the act as a step forward in preventative measures. No doubt, as I get further

down I'll have a few challenges. As we get to committee I'll have a multitude of

questions about the process, the control mechanisms, the partnering with

entities there, the process of how we got to this, but that's secondary. What I

want to talk about here now is the intent of this bill and how positive it is if

we can move it and ensure that it meets the prescribed needs that it was set up

to do.

As we

talk about in communities – again, I relate back to my home community of Bell

Island – there's an organization set up, it's called Unity in Our Community.

It's solely set up to address the opioid issue that we have over there. It's

unfortunate that it had to be created after some deaths in our community from

overdosing, but out of darkness sometimes comes some light.

I've

been fortunate enough to go to some of these meetings and see the addicts talk

about what they're struggling with, and they're there. They're in a room,

they're addicts. They're telling us they're going to have to leave to go get

their fix, but they still want to be part of knowing there's a better life for

them. They just need the supports.

I've

been in a room with people who are going through their recovery and the

challenges they had. I've been there with people who've been off it for two or

three years and what that means to them, but every day they still struggle with

the supports.

I've

been there with families who've lost loved ones and the impact that has, and how

they want to prevent it happening to somebody else. Some of the signs they never

saw. Some of the safeguards that could have been put in play that just didn't

exist, and still don't exist, but need to be moved forward so we have a better

opportunity to ensure the next group and the next generation down the road can

be identified that this doesn't become the epidemic that it is right now, where

it doesn't continue and we start addressing it and we start dealing with the

issue and we start supporting those who have that particular need.

As we

get through this legislation, there are a lot of really good points there that I

think can be part of that. The monitoring, obviously, has to be one. If we can

ensure that only those who should have these opioids, to have access to it, if

we can identify there's abuse in some part of the mechanism, then we need to

deal with that. We need to deal with it in a number of ways.

One, we

need to be able to immediately stop the abuse from happening or access to those

particular opioids so people can't continue their destructive lifestyle. We also

have to make people accountable for their actions. When I say people, I didn't

say these may be the entities, the professional people who are giving it an

understanding. No doubt, they all are part of a bigger philosophy here. They

take an oath to do what's in the best interest of their patients, and 99.9 of

them follow that process.

We also

have to acknowledge the fact that there's a criminal element that will find

creative ways legally to get something that legally should be used, but to be

used in an illegal manner. So there's a continuum there where your law

enforcement agencies would have to work with your prescribers and with your

dispensers, and with the underlining over umbrella organization which, to me,

should be some kind of a board made up of professionals who would monitor the

whole process and keep it in line with other types of entities we have that

enforce regulations, open up lines of dialogue that promote education and also

help develop partnerships where support mechanisms can be put in play.

What

this legislation does, it does start that. I've looked at a number of other

jurisdictions and I've seen where they've started this process. Some have been

very successful. Some have the good mechanism, but the mechanism on paper

doesn't necessarily mean you're going to have successful results. The key

components that go in the continuum, there are some breaks in the line and

obviously the outcomes haven't been where they need to go.

There's

no doubt, like any policy or any program, there's going to be tweaking. There's

going to be some assessing exactly what's the best move forward. There's going

to be some addressing how we better use the resources we have and how we better

develop partnerships as we go through the whole process itself.

I also

have to talk about the functionality of the intent here. The functionality is

not to reinvent the wheel. There are a few things here that I have some deep

questions about when we get into Committee asking for particular clarification,

but the functionality here is not reinventing the wheel, using some of the key

things that we already have here.

The

Pharmacy Network, something that's been talked about, it's been piecemeal for a

number of years. I have to acknowledge it's now up and running. I've talked to

some pharmacists and they said there are still some challenges with it, but it

is being tweaked. Every day there are nuances here where there are suggestions

that people are finding better ways to ensure the information and the intent of

it is actually meeting those goals. So we've come a long way to do that.

There is

no doubt technology will improve such that everybody will have access at a

moment's notice. It will be able to draw down on that information. The

information that's accessible is the information that only those who should have

access to it – which becomes an issue around putting out so much information and

having so much more information accessible. Who is it accessible to? That has to

be some of the safeguards.

There

are some things within the act that I have to be satisfied, at the end of the

day, the safeguards are in play. The information, the privacy part of it, that

people shouldn't have access to the general public or beyond those who would

necessarily need it, there should be a mechanism put in play to ensure that.

There are a number of questions we'll have related to that.

The

whole concept that was noted about: How do we better engage the existing

resources that we have? Like you said, using the Centre for Health Information,

they have a decade of expertise. They've been refurbished. They've been

realigned. They've set out what has worked and what hasn't. They've tweaked

certain programs and services there. They found a mechanism that would better

capture our information and better segregate it so it's usable for what

particular needs.

I think

noting and agreeing with this part of the act of taking the Pharmacy Network and

adding some additional information so we're being able to extrapolate some

additional information so that the Centre for Health Information can identify,

if indeed there are some issues there around abuse, overuse or misuse.

There

are three components here that we have to look at. We can't label everybody in

one category or another; there are different segments as to what would happen.

I do

agree whoever prescribes, whoever dispenses are responsible for exactly what

they're giving out. Now, to what level of responsibility? Well, the ultimate

responsibility, and I know they all feel the same way – it's about ensuring that

what is being prescribed would be a benefit to the particular patient and not in

any way, shape or form be detrimental to their well-being and their health.

In some

cases, it's acknowledged, we have to live. We don't live in a utopian society.

There are going to be people who take advantage of that. So we need to be able

to find the mechanisms to put in play to ensure that our society is safe,

particularly from that part of potential abuse.

We know

from a financial point of view it's a very lucrative business because, again,

when you're an addict, you've got to have that. In a lot of cases, unfortunately

– and this is testimonials from some young men and women and older citizens who

have said – it gets to a point where you'll almost do anything to get that fix

that you need to have it.

How do

we get to a point where we know there's a trend? Some will tell me that they

started where they could take four and five pills a day and that was quite –

then it was eight or 10. Now it's 12 and 15 and sometimes they're up to 20 and

30 pills a day to get their fix. They're finding all kinds of stuff.

I've had

horror stories where people have told me they went and broke their leg

deliberately so they could go in and get prescriptions because the doctor had

already caught on to them knowing that they were abusing it. But then they'd go

in to emergency and you have a broken leg, a doctor has an oath and a

responsibility to fix that. Obviously, they know you're not faking pain when

you've just put pins in your leg. Now you get your prescriptions again and now

you're back into a trend of being able to manipulate that for as long as

possible. That's part of the whole process.

becomes unfortunate that we've gotten people into that mode. As was noted,

sometimes it is ill-fated processes of what these opioids were intended to do to

what they're actually doing to people.

Conspiracy theories – is it that some companies didn't share all the data in

their research of the impact it would have on people? And that some people might

be more susceptible to becoming addicts and this becoming their health disease?

Is it deliberate? Was it lack of research at the time? Was it that there was a

need for a particular intermediary opioid to address something that wasn't

addressed? Did we build up a resistance to particular painkillers and this over

a period of time? There are still all kinds of discussions out there as to how

we've gotten to this point where opioids themselves have become so addictive and

become so reliant on them.

There's

been a whole discussion here around how we address moving forward on this plan.

The Prescription Monitoring Program is a first step, no doubt, and it is not in

isolation because there are a number of other agencies out there who've been

doing yeoman service in trying to address the needs around curbing addictions to

opioids, access to opioids, prescribing of opioids over a period of time but,

again unfortunately, sometimes are working in small silos, in isolation.

What I'm

hoping this will do and what I think it has the framework to do is bring all

that in line, try to bring it under one prescribed philosophy, if nothing else.

It doesn't force everybody to do their part out there, but it does particularly

identify, from a monitoring point of view, the amount of use, who are using it,

where they're getting it from and particularly what the time frames are within

that prescribed use and dispensing. I see a number of benefits from where this

can take us into addressing the opioid epidemic that we have here.

I'm glad

that the minister talked about other jurisdictions and identifying where there

are some challenges in other ones. In my own review of other provinces and how

they implement them – and other than Quebec, everybody else has some form of

legislation. Some, it's under existing legislation. In our case, it could have

been under the Centre for Health Information legislation if we wanted that to

be. Having a stand-alone piece of legislation, I'm not adverse to it. I see

sometimes there's strength in having something forthright and upfront so people

understand that this is being taken seriously and it spells out exactly

responsibility, it spells out exactly the intent of the act and it spells out

exactly what you would hope the outcome would be as you move forward.

One

thing about a piece of legislation, there's nothing preventing you from coming

back and making changes over periods of time. As you assess the success, as you

develop more partnerships, as you understand there are other segments to what it

is you're trying to address and then as you get to that area in life, you make a

decision that we need to either upgrade something or there's something here that

we need to remove, or there's a whole new angle that we need to go to ensure

that legislation meets the need that it was set up to do.

In this

case, contrary to what people may think, this is a very encompassing piece of

legislation because it outlines a number of key components here. It's not only

about the standard legislation of the intent here and the intent about

education, supporting, about putting in play the mechanism; it also outlines

exactly who the stakeholders would be, their roles and responsibilities. It also

outlines exactly the process, and there's a legal component here. This is just

not fluff and data collection for the sake of data collection. There's a legal

component here. This act here will have legal ramifications for professionals in

a multitude of health-related professions here about following rules and

regulatory processes, but particularly from a legal point of view.

When, in

an act, you note your Royal Newfoundland Constabulary, when you note your RCMP

and you note other specialized policing agencies, then you know this is a

serious bill. Then you know that what's being discussed here is being taken

seriously, and that there's a full-fledged umbrella process here of

accountability and people have to live up to that accountability.

So I

just want to take you through some of the things for the bill because what

people may not realize – well, what does this include? Is it just a bit of fluff

that we're going to have a computer program and now we have two more blocks on a

sheet when you note it? In principle, it's an easy way to say we're going to

collect more data, but the data collection is only the first part of a bigger

picture, and the bigger here is how we address the opioid epidemic. How do we

ensure that the resources we already have in play can be used? How do we ensure

that those who are not following the ethics, the morals, the proper procedures,

the legalities are accountable and, more importantly, can be stopped from doing

things that they're not legally allowed to be doing, and are doing things that

are detrimental from a health point of view?

There

are a number of agencies here. We're talking about the Medical Association,

we're talking about the Nurses' Union, we're talking about the pharmaceutical

association and we're talking about the dentists. There are a number of people

here who have the ability to prescribe opioids and have the ability, on a daily

basis, to be seeing those individuals, those patients, who may be at risk of

becoming addicted to opioids, or themselves who are already addicted to opioids.

So even

that data there, even that collection data there, that resource is a positive to

be able to ensure that we start addressing the issue and make the connections

between all those who are out in our society who have it their main objective to

try and improve the lives and address issues around opioids.

I just

want to read some of the key components because as I go through those, I may

note some of them; I may get through them all before my time is up. If not, in

Committee I'll have a number of questions for the minister and, no doubt, the

minister has had dialogue with a number of stakeholders out there. I've had some

dialogue with a number of them over the last couple of days, but prior to that,

on some other issues, but now, particularly, as it relates to this act.

There's

no doubt, everybody has concerns. Everybody has, as their primary objective, the

philosophy of finding a better way to address opioids. I found nobody, no

agency, no particular group, no head of a not-for-profit organization who's

adverse to us in the House of Assembly having

an act that addresses prescription

monitoring, particularly around opioids.

Keep in

mind – and it was noted, particularly in the press conference – the issue here

is about monitoring drugs. The list right now is restricted to opioids, but that

doesn't mean it wouldn't be restrictive. So that's a discussion that we'll have

with the minister in Committee as we get there.

The

primary intent here is about the immediate challenge that we have in

Newfoundland and Labrador and it's about those opioids. The act itself, while

it's generic in what it's doing and it's open – that it can continue forever and

a day adding new drugs to it as if they're deemed that they have a major impact,

that we need to be able to collect that on a more precise basis, and have to

have more safeguards in there. And have to have a monitoring process there that

becomes a watchdog to ensure that the use and/or misuse or misguided use is

being monitored, identified and dealt with by a particular agency authority or a

particular supportive intervention organization.

That can

be done simply by identifying the information that's – first, where it came from

and then, subsequently, which agency is best equipped to deal with that. I want

to talk particularly about some of the issues that are here around the

difference between how we will probably be implementing or what's being proposed

here versus some of the other jurisdictions.

One of

the biggest challenges that I have here – and it's no disrespect to this

minister or any other minister – is that the minister in this case has absolute

power. I have a struggle with that. I have a struggle with that with any piece

of legislation when a minister has absolute power over exactly what's being

done.

understand ministers are there to guide. Ministers are there – they have a

responsibility for their line departments. They're the umbrella guiding light

for programs and services, no doubt about it. But when I looked at other

jurisdictions and couldn't find any that were similar where the minister has

carte blanche control over the whole process, I tried to find something that I

felt comfortable with.

Nova

Scotia has a better process where a board is put in place. I have no qualms with

the minister or Cabinet or the process where appropriate board is selected to

monitor this. We have the Centre for Health Information, so we have a mechanism

in play where the information can be stored, disseminated and then broken down

to see how it's addressed as part of that.

But in

this case here – and I just want to note because when we get in Committee I'm

going to ask the minister then for a little bit more clarification about

responsibilities of the minister. As we look at them, they are prescribed

basically that the minister has total control over every aspect of this. Now,

the minister does have the jurisdiction to be able to designate somebody, and

that's fair enough.

From a

personal point of view, I would of rather have a bigger umbrella group that's

already put in play prior to that with the minister's endorsement – not the

minister's control, the minister's endorsement – because this organization or

agency or board, in a number of jurisdictions, would have the professional

ability to monitor the process here and come back with a set of recommendations

to either the minister and then to the House of Assembly, about changes to a

particular legislation as part of the whole process.

here's just some of the things here: “The minister may, in accordance with the

Act and the regulations, enter into an agreement relating to the sharing of

information with the following persons: (

a) a dispenser; (

b) a prescriber; (

c) a

regulatory authority; (

d) a law enforcement authority; or (

e) another person

prescribed in the regulations.”

May – if

there was a board here that was made up of these particular individuals, then

that information would be directly shared within the confines of those. And all

these agencies already have a vested interest; they're already part and parcel.

They're the ones who monitor, they're the ones that are the authorities who

police agencies; they have a set of guidelines that must be followed. These are

things that are very important, I think, to sustainability, but success here.

Because these are the players who all – there's a continuum here of assessing

which agency, if it's a registered nurse who sees a particular client, who

refers them a doctor, who does an assessment, who prescribes an opioid for that

aliment to the pharmacist, who fills that, that has that effect. Or we go back,

there's another component here, there are dentists who are involved because

somebody just had a root canal needs a particular thing.

Having

access to knowing of what the file is for that individual. And that's why I want

to bring it back to the real intent here. The real benefit I see is that there

will be one file on your screen where you bring up, will have all the

information, particularly around that individual's use of opioids.

Now you

got four or five lenses. If people do what this is intended to do, the health

professional, you have four or five lenses to take a particular look at the use,

the prescribing, or again, as I said, the overuse or misuse of particular

opioids. All of these professionals would have to be in some way, shape or form

– no doubt, they're already trained, they're professionals, they're health

professionals. In some cases they spent eight, nine, 10 years in post-secondary

education being trained to identify particular situations, but there would have

to be some additional supports and training here to identify here's a potential

red flag or here's something I should go back and identify.

I do

like that there are a few extra things that need to be done when you're doing a

prescription from a prescriber point of view about some of the issues. Is this

the first time that I've had somebody actually come in? Is it the second time

somebody has come in? Is this a continuum? My assessment was that this injury

had been healed; why is this person still depending on that?

I mean,

there are things that a doctor, no doubt, asks themselves every day when they're

doing it. And a pharmacist again, because it's storefront, when they're people

coming on a continuing basis, when they look at their file, would say there's a

red flag here. This person hasn't had a major alignment. Why is this now another

prescription two weeks later?

It's to

identify if there's some way, shape or form one component or a collaborative

approach by a couple of components, be it the patient or physician or somebody

else have collaborated to move more opioids or prescribe more opioids than they

should. Is it the criminal element has found an illegal way to address this?

We've heard stories over the years about stealing prescription pads and people

filling them out and these type of things, but again the more safeguards that

are in play, the better it is.

There'll

be questions around what is the impact that it will have on the physicians from

a time point of view, from a report point of view, the same with the pharmacists

from that point of view. They are smaller nuances I think can be worked out. I

would think that most of these agencies would be welcome to more dialogue, more

consultation about finding out how they improve their role and how they use the

mechanisms they have or the infrastructure they have to make this less

encompassing and to ensure that it meets the particular need that it was set out

to do.

There

are also issues here around how we move things when we get to law enforcement

authorities. What real stake would law enforcement agencies play in this? What

role will they play with the prescribers, with the dispensing? What role will

they play once things are identified, once it becomes a legal matter, the

process – and I know it's outlined here in certain areas of the regulatory

bodies that would then make decisions as to how they deal with what they think

is an infraction. Do they then refer it to one of the police forces or to a

legal entity to take it to the next level rather than it just being an in-house

review and then respective punishment levied on that individual or that group of

individuals? Does it become a bigger issue where it becomes a legal matter where

police forces have to come in?

Then we

talk about the access they would have to information. That becomes one of the

fears here. What we're doing – and this is not about fear mongering, I want to

make that very clear. This is about ensuring that all the components are thought

out, so that information being shared on health information is relevant to

exactly what the issue may be here. If it's opioid abuse, fair enough. If it's

relevant to something else, well, then that health information has no bearing

and nobody else should have access to that.

There

are decisions that would have to be made there. There's no doubt, the

authorities that have a speciality in that particular field should be able to

identify that, but I think there's a little bit of work that needs to be done

and a bit more consultation around those particular areas to identify what's

acceptable.

If we do

an investigation in a particular area, what health information – if it's about

opioids, has something happened from an ailment previously? It may be a mental

health issue before that. It may be something else relevant to your health over

your lifetime. Should that information be made available, too? Is it a carte

blanche that your health file is available to that entity for review and to

whoever the minister may designate as their representative or the designate for

inspectors when we talk about coming in doing audits and that?

Some of

the entities haven't necessarily said they have problems with this. What they've

said is they need clarification. What would the rights be if all of a sudden an

inspector can come into a pharmacy and say I demand this file? Well, which part

of the file do you demand? Does it have anything to do with someone who had an

antibiotic? Are the antibiotic ones also going to be added to these lists? Those

continuums here need to be clarified, at the end of the day, exactly what it is

the inspectors and the auditors would have access to, because then there's a

real challenge about your privacy. It becomes about your privacy.

People

will tell you they would rather somebody know their income than to know what's

in their health file, because people are private around their health conditions.

Now, if it's something that's illegal, if it's something that's been done

without following proper regulations, I have no qualms here that that

information should be accessible to the authority or a police force to

investigate and identify whether or not there's been a violation and then the

appropriate action taken.

The fear

I have reading this is there are many unknowns here. That's the thing, there's a

lot of information here. I give credit, there's a lot of clarification in some

areas. There are a lot of acknowledgements in some areas, maybe not as much

clarification in some others as to where does it start and where does it end in

certain areas. When you talk about health information, it's something that

people are very wary of having the general public, or people who are designated

within the general public, to be able to go and access that type of information.

there's a fair bit of clarification here that I will want some clarification in

Committee, no doubt. I know there are a number of agencies out there who want

some clarification. Only last night when I had a chance – only getting the

briefing yesterday – to get my head around it and bounce it off some other

people, just average citizens like the rest of us, who would want to know what

impact does it have.

Again,

I've got to be forthright and upfront. Nobody is averse to us finding a better

mechanism to identify how we deal with opioids. Nobody is averse to putting a

mechanism that prevents those who shouldn't have access to it having access to

it. Nobody is averse to finding a mechanism that ensures the few bad apples that

we have in a particular profession are identified and dealt with harshly,

because we know the impact this has. This is not just nickel and dime stuff.

This is having a dramatic effect on people's lives. There's nobody averse to

developing a collaborative approach to addressing the opioid issue.

There

have been a number of issues that were thrown at me, particularly when it was

noted yesterday in our briefing – and I shared it with a couple of citizens I

spoke to last night – that this is not exclusive to opioids. There could be

other drugs put on the table.

What are

the mechanisms that are used to identify that these should be part of the

monitoring list? They're some legitimate questions, and I'm not an authority by

any stretch or know anything even remotely close to understanding how or why

certain things would go on, but it was a little alarming when I heard we need to

look at one that possibly could go on, it could be antibiotics. I need more

clarification to understand where or how would an antibiotic – is it over use?

Is it that it's not fitting the needs now? Is it that we're not prescribing in

the right manner? I don't know. These are things that worry me.

What

worries me, too, is then what other ones get added without it being fleshed out

fully to understand the impact? Do we willy-nilly start adding things? I would

think that wouldn't happen here, but my fear is there's an open-ended process

here that doesn't prevent that.

So I

think every now and then – and we've gotten caught in this House of Assembly,

the present administration, the previous administration got caught with

legislation that had holes in it. We were so caught up in doing the right thing

that there were so many nuances to it, a few things slipped through.

Again, I

went out to people in society and they threw little things at me that I wouldn't

have thought of and I got a briefing on it. There are people who have had no

briefings but have been able to identify certain things just in asking

questions.

There's

no doubt, that's what this debate is all about. It's for us to talk about what

our understanding is of the particular bill, what our understanding is of the

intent of the bill and what our understanding is of how the bill could be

implemented.

While we

do that in debate – there's no doubt, I've sat here sometimes shaking my head.

No way would I agree with a bill that was coming in. After the debate and the

clarification and Committee questions and answers, I would nod and say: Yes, I

get it now. I understand.

There's

always some apprehension here and there's no doubt, there's always – all of

these are live entities. They're continually being looked at. They're

continually being identified to see and evaluate it, and then we come back to

the House and change legislation. This is a particular difference because this

is the first kick at this.

didn't do what some jurisdictions did and already put it as part of one existing

piece of legislation. I'm not averse to that. At this point, I have no problems

with that. A piece of stand-alone legislation that addresses a particular need

right now and particularly such a serious need, I have no problem supporting

that.

There

are some challenges here around part of the policing process, part of the access

to the files, part of who has access to that, part of the designate, who, where,

when and how the designates are going to be put in play, how the reporting

process works prior, during and after and who the reporting comes back to. It's

here, but it's in general context: may, shall. It's a bit vague in some areas

and I'm going to be looking for clarification.

The

other thing is about the minister having full control over the whole mechanism.

It's only recently that we went the opposite. In one piece of legislation that

we passed in this House recently, we took the minister out of it because it was

felt you don't want the perception that a minister could micromanage and have

undue influence on a piece of legislation or a program or a service other than

being responsible for the legislative part of it and ensuring that the

information, the research and the coordination moves forward. That's the general

context.

I've

been a minister. I understand that philosophy. There's no doubt there are times

I wanted to micromanage things that we did, but that doesn't make sense. You

can't do that. To put it in legislation worries me. It worries me because a

particular minister being able to do 20 things and make decisions on 20 things

consistently in one piece of legislation, when there are agencies and

organizations who have and have had for the last decade or century authority

over these types of services, the providers who provide those, the input into

legislation that monitor what they do and to the actual day-to-day interaction

with the clientele that they're trying to serve.

For a

minister to be able to have carte blanche over that, I have some real concerns.

Now, I'm open-minded; I can be sold if there's a rational reason that's

different than my mindset. That's fair enough. I'm open to that. No doubt, I

think we're all open to having that discussion on this side of the House, but we

need to get to that part of it.

I only

bring that up again because it's one of the few times I've seen it where the

minister has so much control over a piece of legislation. It says here: “The

minister shall (

a) administer the program; (

b) monitor the prescribing and

dispensing of monitored drugs; (

c) evaluate the effectiveness of the program;

(

d) provide information, professional consultation and assistance to the

regulatory authorities relating to the prescribing and dispensing of monitored

drugs;(

e) monitor the use of monitored drugs: (

f) educate prescribers and

dispensers regarding the appropriate prescribing and dispensing of monitored

drugs; (

g) educate individuals on the appropriate use of monitored drugs; (

h) report to the regulatory authorities on new and emerging prescribed patterns for

monitored drugs; and (

i) perform any other duties prescribed in the

regulations.”

Now,

these are normally – I've seen this in legislation, but it's never the

minister's responsibility; it's board chair, it's the regulatory body, it's a

particular agency. To have the minister given full authority over all these

things, obviously, as you read that, it's pure micromanaging if the minister was

to do that. I know no minister would ever do that. I would think that's not the

intent here. No matter what their skillset was, the time frame would never allow

them to do this. These are things here that are somebody who solely, fully

entrenched in doing that particular job. This would be somebody's full-time job

to do this.

Obviously, the Minister of Health and Community Services has a multitude of

other responsibilities that would take them in other directions also in

performing their duties. So that's why I ask is it necessary to have this in

here and what the intent was. As I went through some of the jurisdictions, I

couldn't see that that was the main philosophy here. I see the minister shall

appoint a regulatory organization, a board, a representative to do exactly

what's outlined here. I see all that. I see the benefits of that. I see how that

would be, in my opinion, a better way to move things forward because, from my

philosophy, on a daily basis somebody or some group, or some organization or

some board would have that responsivity. That board, particularly, would be made

up of a multitude of people who have a vested interest here because they come

from the regulatory bodies, they come from agencies that have set out,

particularly, the responsibility around addressing opioid monitoring and the

impact that it has.

I see a

benefit from that, and that's why I particularly like Nova Scotia's. Not

everything in Nova Scotia was perfect. I like the fact that we have taken some

of our own approaches in some other categories here and other sections. I like

that we've taken some from BC. We've taken some from Ontario. There are some

there from New Brunswick. We've been encompassing those to do that.

The one

I don't see, the trend across the country, is that the minister has carte

blanche. The fear in carte blanche is, again, and I mentioned earlier, what

other drugs can be added. I think somewhere here it notes that minister would

recommend to Cabinet additional monitored drugs to be added to the list. I have

a concern about that, too.

I would

think this is where the agencies and organizations, the authorities that have

the speciality in that area, would be the ones that would make these

recommendations, through research, through consultation, would identify exactly

what the issues are. I would see also from public acknowledgement that these are

the challenges we have. There's been a trend in a particular drug, either being

abused, misused or over prescribed as part of that whole process.

That

would be, to me, a very functional process. I would think 80 per cent of the

legislation we have here, where there's a regulatory process of monitoring and

reporting back and engaging and then making modifications to exactly whatever

that program operates has, somewhere along the way, a monitoring board or agency

who oversees all of that. Legislation that I've been part of, that's normally

how it would work. When you have legislation that is relevant to doing research,

monitoring, overseeing, implementing, somebody has to do that. It's not at the

minister's level.

I find

this a little bit concerning, a little bit bewildering, but I'm open for

clarification. I have no qualms on that, getting that clarification as to why

the government decided to go this route. That will be curious. I know some other

agencies have asked the same thing.

I do

have another concern around – and I noted it earlier – the access to the

information. I particularly would want to have some real clarification on how do

we ensure that the opioid process, when a pharmacist goes in or a doctor goes in

to review the file, and they both have responsibilities and access to it,

because they do, the information that's there that if, indeed, a red flag is

noted and a designate, an inspector, an auditor comes in, what is it that

they're auditing. Are they auditing the whole health file? Are they going

through everything relevant to somebody's perspective? If that's indeed the

case, then I have a challenge on that, too. I have a challenge because that's

not the issue that we're addressing right here.

that's a bigger issue that your health information now can be easily and readily

made available to anybody, to a police force who comes in because somebody has

been accused that you've been overprescribed medications, or you've overused

them or you've illegally accessed them, then that's a different story than

what's also in your health file. That may be relevant to people in your family.

In your health file, doctors take notes and there are things there relevant to

discussions that took place about situations of how your ailments occurred or

things relevant to that.

I think

we have to go back to a balance. The minister said this is at the beginning:

This is about a balance. I agree. It's about functionality and it's about

balance, the functionality of using the resources we have. The Centre for Health

Information, the Pharmacy Network, a multitude of very highly trained

professionals dedicated to their particular fields and their expertise to

identify and weed out the very small proportion who are not following the

regulatory and legal matters here, to identify better ways that we can help the

particular patients, and that what this is about – or the particular citizens

here. It's about the fact that we're identifying opioids because they're having

a major impact on our society and a major impact on individuals in our society.

This is

a proactive approach here and I agree with it. It's proactive because we're now

going to outline a strategy that first gets at the root of the situation here,

how people have access to these opioids. Time frames – and I mentioned that

earlier, who prescribes in this. Is there a mode? Is there a consistency here?

Is there a different approach we can use?

The

gathering of information is important because it will weed out those who are not

following the process. But I'm thinking the information, too, can be better used

through one of these regulatory boards or the board itself – I would think the

advisory board – to identify other streams that may be added here. If we add

this here, if it goes to the prescription monitoring, maybe there are other

components there that can identify other issues that pharmacists and

prescribers, doctors, deal with when it comes to better use of health, better

interventions in our health-related supports.

There's

a whole mechanism here that should be used. I noted the minister talked about

consultations, and no doubt the people that were involved in these consultations

wholeheartedly have an expertise in these fields, wholeheartedly are committed

to what they're doing there, but I am hearing from a number of them, some who

were involved in this. That while they want this to happen and they know it's

needed, that there's still some consultation. There are still some things that

need to be fine-tuned here to make this more effective.

It's

probably better that we delay it for a little short period of time to make sure

it's done right and meets its particular needs and it's effective the day it

becomes real and it's in a real-time process. To start it and then halfway

through have to come back and say this is not working the way we wanted it and

then put everything slow. Once the momentum starts and you stop it, it takes a

lot longer to get people on side again and keep moving things. So if we're going

to do it, let's do it. Let's fill in any of the gaps that may be identified.

There's

no doubt there's some inclusion here with some other stakeholders, there's no

doubt of flushing out a little bit more of the

definitions on some of these.

Maybe these are not all the right approaches in some areas, but I've gone

through it. A lot of this, a fair bit of this to me would fit the needs of what

we're trying to address here, but there are a couple of challenges and I've

outlined some of those. No doubt, some of my colleagues will outline some of the

other ones that I haven't.

I want

to go back again, and there are two things I want to reiterate. I want to

reiterate, first, my personal support for the philosophy and the process here

and the intent of the bill. A majority of what's in here, the regulatory

components here are very efficient. They spell out exactly what would be

engaged.

I do

want to emphasize the challenges I have here around how we determine which drugs

get added, outside of the opioids. I understand that and I understand why we're

going there and we're going to label them in one category, and rightfully so. We

need to do that. We need to immediately start looking at how we address that

particular issue. So put them in that pot, that's fine.

I have a

fear of an open-ended process where at a whim or at somebody's suggestion,

Cabinet can decide there are other drugs going on that, without knowing exactly

what process is followed there. Is it a set of recommendations from a board? Is

there research done on something relevant to that?

So I'm

going to want some clarification around what the process, the intent of the

process, and what the plan would be from the minister and from the designate or

a committee he may strike. Also, again, clarification around the ability to

ensure that people's information is not readily accessible to those, other than

those who directly should have it, relevant to whatever that issue is.

In this

case, the issue is around overuse, misuse, misdiagnoses when it comes to

opioids. It's an open-ended file that when an inspector comes in or an auditor,

they take that and they have access to all of that. How are we going to ensure

safeguards there around people's privacy?

I'd like

to know what the Privacy Commissioner's view would be on this because,

obviously, this is a new piece of legislation. I'm not quite sure what input

he's had to it. If he only got it yesterday like I did, I'll be three weeks

trying to figure out exactly what each clause means, or what the intent of each

clause is. I'm hoping to find that out when we get to Committee because I'll ask

the minister in a number of cases to clarify exactly where some of those issues

are.

I also

have, as one of it is, again, a board. Somewhere along this process I feel there

should be a board established, made up of the professionals. I don't just mean

the regulatory ones who will be the policing bodies to ensure if someone

violated something that they're punished properly, or it's addressed in a manner

that is befitting that particular classification or that particular profession.

What I'm

talking about is an overarching agency, board, that would ensure that this

legislation is being enacted, that it's being monitored to find out if it's

meeting its needs, and then that there's a set of recommendations coming back.

Some of those might be recommending back to the minister, who in turn takes it

to Cabinet, who in turn takes it to this House and says we want to add this list

of other drugs because here are the impacts they're having, here are the

challenges we have or here are the concerns we have. All legitimate, no problem.

I have

no problem with the process. I have a problem with who is responsible for

certain components of the process here. One is the minister having full-fledged

carte blanche control over it. The second is we don't have a stand-alone,

upfront board, organization that would have the regulatory advisory capacity to

ensure that this House has more advice, more open debate, more recommendations

as to how we improve this because it's the first kick at this.

This

again, as I mentioned earlier, is a living document. It's going to grow, it's

going to be changed, it's going to meet different needs. So we need some

organization out there, some entity and a regulatory board that we have here, or

an operational board, an advisory board that some other jurisdictions have to me

would fit that particular need. Particularly, when we already have agencies who

could suggest, or put somebody there who would come with the knowledge of how

they could, from their stakeholder's point of view, improve this piece of

legislation and ensure it meets its particular needs. That's another one of the

issues I have.

The

underlying issue here is about – we talked about assessing, improving,

educating. I'd like to know a little bit more of how we're going to do that. Is

this a resource related thing we're going to do? Are we going to develop better

partnerships? Are we going to take it and run with it the way we should?

Are we

going to now make this a living entity, so continuously every one of these

organizations will have an open-door process to come in and recommend? Here's

what we found. Here's how our members feel that they can better improve this

piece of legislation and ensure that we as a society here and we as a government

and we as the citizens of Newfoundland and Labrador can ensure that the

challenges we have and the epidemic we have with opioids are being addressed.

The best way to do that is to have open dialogue, have a process in place, but

have those professionals who best advise government.

Mr.

Speaker, I'll have a chance to talk to this again in Committee.

Thank

you, Mr. Speaker.

SOME HON. MEMBERS:

Hear, hear!

MR. SPEAKER:

The hon. the Member for Burin

– Grand Bank.

MS. HALEY:

Thank you, Mr. Speaker.

Mr.

Speaker, it's my privilege to rise in this hon. House today to participate in

the debate on Bill 25, the Prescription

Monitoring Act .

Mr.

Speaker, I'm sure we have all heard the very sad stories of abuse and overdose

related to the use of opioids. Our province is not immune to the opioid crisis,

Mr. Speaker, people are dying from overdose.

In 2016,

in Newfoundland and Labrador there were 57 hospital admissions involving opioid

poisonings and 16 apparent opioid-related deaths. What may have been seen as a

problem in other parts of Canada and the world is now on our doorsteps. Mr.

Speaker, the deadly drug fentanyl is now on our streets.

We all

have to recognize that prescription drug abuse, especially opioids, is a real

issue that impacts the lives of Newfoundlanders and Labradorians every single

day. We all have to do our part, Mr. Speaker. The provincial government, the

Members of this hon. House, the public, our communities and our front-line

health care professionals need to work at finding ways to reduce and address

this very serious and real public health issue.

Prescription Monitoring Program is a tool that can help address this opioid

crisis. It can help improve the prescribing and dispensing of monitored drugs

and controlled substances. It can support ways to lower or prevent the harms

related to these drugs, Mr. Speaker, and it can help identify patients who may

be at risk of addiction.

Every

province in Canada, except Quebec, has some form of prescription monitoring. A

Prescription Monitoring Program is not intended to prevent the use of opioids

for legitimate medical purposes. There are many reasons why an opioid is the

most appropriate treatment for a patient's condition. The Prescription

Monitoring Program, Mr. Speaker, is not meant to deter prescribers from making

an informed clinical decision to prescribe an opioid. Rather, it assists

prescribers by providing them with necessary and available information to make

the best clinical decision for a patient.

Bill 25,

the Prescription Monitoring Act , which

sets out the legal framework for the province's Prescription Monitoring Program,

is another step in our government's Opioid Action Plan. The Opioid Action Plan,

which was launched in November of 2016, includes a number of initiatives aimed

at addressing the opioid issue, including a new mandatory safe prescribing

course for physicians, public awareness and education program on opioids,

naloxone take-home kits and naloxone pop-up tents.

The

Prescription Monitoring Program and Bill 25 will also meet one of the

recommendations presented in the Mental Health and Addictions Action Plan, Mr.

Speaker. The Prescription Monitoring Program will build upon the success of the

provincial Pharmacy Network. The Pharmacy Network is a component of the

electronic health record, which is commonly referred to as HEALTHe NL, that

allows dispensers to contribute to the access patient medication profiles in

real time.

HEALTHe

NL is a private record of an individual's health care information, Mr. Speaker,

available electronically to authorized health care professionals. It integrates

information from many sources into a single lifetime record of an individual's

key health history and care.

As of

this spring, all pharmacies in Newfoundland and Labrador were connected to the

Pharmacy Network. The Pharmacy Network gives health care professionals access to

a person's medication profile. Mr. Speaker, when a prescription gets filled at a

pharmacy, the Pharmacy Network stores information about a person's medication

history. The Pharmacy Network makes it easier for pharmacists and other health

care professionals to make more important informed decisions about care and

helps prevent harmful drug interactions.

Data

from the Pharmacy Network shows that benefits are already being realized. There

has been a decrease in adverse drug events, there has been a decrease in

prescription errors and there are reduced duplicate prescriptions, Mr. Speaker.

The

Prescription Monitoring Program will operate in tandem with the Pharmacy Network

to detect an alert to questionable activity when a prescription is filled. For

example, it is intended that the program will automatically flag where a person

has visited multiple physicians or pharmacies within a defined period to get

more opioids.

Other

activities that may be flagged include where patients on an opioid-dependent

treatment receive prescriptions for other opioids, where opioids are prescribed

or dispensed in a supply of greater than 30 days and where patients attempt to

create multiple patient profiles at multiple pharmacies.

With the

program, there will be a stronger ability to identify excessive and

inappropriate use of a number of serious drugs such as opioids, Mr. Speaker.

Bill 25

states that the objects of the Prescription Monitoring Program is to monitor,

analyze and report information related to the prescribing and dispensing of

monitored drugs in order to educate, support and assist individuals on the

appropriate use of monitored drugs and to educate, support and assist

prescribers and dispensers in appropriately prescribing and dispensing monitored

drugs.

Monitored drugs will be prescribed in regulations to initially capture opioids.

The Minister of Health and Community Services will be here to oversight the

program. The minister will be responsible for administering the program;

monitoring, prescribing and dispensing practices of monitored drugs; evaluating

the effectiveness of the program; providing information, professional

consultation and assistance to the regularity authorities relating to

prescribing and the dispensing of monitored drugs; monitoring the use of

monitored drugs; educating prescribers and dispensers about appropriate

prescribing and dispensing of monitored drugs; educating individuals on the

appropriate use of monitored drugs; and reporting to regulatory authorities on

new and emerging prescribing patterns for monitored drugs.

This

bill permits the minister to delegate his powers and duties and it is the

intention that the administration of the program be delegated to the

Newfoundland and Labrador Centre for Health Information. The centre currently

houses a number of provincial electronic databases, including the Pharmacy

Network, from which data and reports will be drawn to monitor and analyze the

use, prescribing and dispensing of monitored drugs.

Under

the bill, Mr. Speaker, a prescriber will be required to check a patient's

medication profile contained in HEALTHe NL prior to prescribing a monitored

drug. Dispensers will be required to record the prescription in the Pharmacy

Network and to check a patient's medication profile prior to dispensing a drug.

Regulatory authorities who license and register prescribers and dispensers will

be required to provide notification where the licence of prescriber or dispenser

has been suspended, revoked or restricted with respect to a monitored drug, Mr.

Speaker.

Bill 25

highlights the importance of providing accurate information to prescribers and

dispensers whose role it is to make the best health care decisions for their

patients. As such, the bill states that a patient is not to knowingly provide

false or misleading information to a prescriber or dispenser.

As I

indicated earlier, the program has the ability to flag certain questionable

activity, such as where a person has visited multiple prescribers or dispensers

to obtain opioids. Where those activities are flagged, officials may have to

reach out to prescribers and dispensers to seek clarification with respect to a

prescription. The minister or his delegate may request information where it is

reasonably necessary to achieve the objects of the program.

Where

the requested information is not forthcoming, Bill 25 authorizes an inspector

appointed by the minister to attend at the place of business of a prescriber or

a dispenser to access information and review documents in order to determine

compliance with the legislation.

Mr.

Speaker, as the object of this bill is to provide education, assistance and

supports, and with the expectation that prescribers and dispensers will respond

to requests for information, it is anticipated that the inspection powers will

be rarely used, if at all. However, such powers may be necessary to address

those very few but most extreme cases.

Mr.

Speaker, Bill 25 will allow for the sharing of information with law enforcement

for investigative purposes where there are reasonable grounds to believe that

illegal activity related to a monitored drug is occurring. It will also allow

the sharing of information with health profession regulatory authorities where

there are reasonable grounds to believe that a prescriber or a dispenser is

acting contrary to the legislation.

Mr.

Speaker, our government has had the assistance of health care professionals,

regulatory authorities, law enforcement and members of our communities in

developing the Prescription Monitoring Program. As a part of the program's

implementation process, there is an intention to continue to engage with these

stakeholders in order to benefit from their advice and recommendations on the

implementation of the program.

As such,

Bill 25 permits the establishment of advisory committees, Mr. Speaker. The bill

specifies that committees must have at least one prescriber and one dispenser as

members. This requirement will ensure that clinical expertise is available to

program officials.

Mr.

Speaker, except for the requirement that prescribers view a patient's medication

profile prior to prescribing a monitored drug, it is proposed that the majority

of the bill will come into force on January 1, 2018.

SOME HON. MEMBERS:

Hear, hear!

MS. HALEY:

The requirement that

prescribers view a patient's medication profile will come into force six months

later on June 30, 2018, Mr. Speaker.

SOME HON. MEMBERS:

Hear, hear!

MS. HALEY:

This delay in proclamation

will allow time to work with those few prescribers who do not currently have the

technology in place to allow access to the patient medication profile. It will

also give prescribers the time necessary to build this requirement into their

practice.

This

phased-in approach is not dissimilar to the process undertaken with respect to a

pharmacy's access to the Pharmacy Network, Mr. Speaker. It is unfortunate that

we have to come to a time in our province where we require a Prescription

Monitoring Program.

SOME HON. MEMBERS:

Hear, hear!

MS. HALEY:

However, misuse and abuse of

opioids is a real problem facing Newfoundlanders and Labradorians. We need to

take action to protect our families, our neighbours and our communities from the

forces of opioid addiction. Bill 25 is indeed an important step in that

direction.

Mr.

Speaker, I take this opportunity to recognize Mrs. Ruby Hoskins of Marystown on

the Burin Peninsula. Ruby is a strong advocate and chair of the Stand Against

Drugs Committee. I say thank you to Ruby for all the good work she has done and

continues to do.

I am

very pleased to support this bill and I ask all of my colleagues in this hon.

House to also do their part and support Bill 25. Mr. Speaker, given the time, I

now adjourn debate.

Thank

you, Mr. Speaker.

SOME HON. MEMBERS:

Hear, hear!

MR. SPEAKER:

The hon. the Government House

Leader.

MR. A. PARSONS:

Thank you, Mr. Speaker.

Given

the hour, I would suggest, with consent from my colleagues across the way, that

we recess until 2 p.m.

MR. SPEAKER:

In accordance with

provisional Standing Order 9(1)(b), this House stands in recess until 2 o'clock

this afternoon.

Recess

The

House resumed at 2 p.m.

MR. SPEAKER (Trimper):

Order, please!

Admit

strangers.

I'd like

to welcome to the public gallery today, Mr. Mark Brown, who will be the subject

of a Member's statement today. Joining Mark are the current and past chairs of

the United Way, Tammy Davis and Kathryn Atkin.

SOME HON. MEMBERS:

Hear, hear!

Statements by

Members

MR. SPEAKER:

For Members' statements today

we have the hon. Members for the Districts of Windsor Lake, Lewisporte –

Twillingate, Fogo Island – Cape Freels, Conception Bay East – Bell Island,

Placentia West – Bellevue, and Terra Nova.

The hon.

the Member for Windsor Lake.

MS. C. BENNETT:

Thank you, Mr. Speaker.

It gives

me great pleasure to rise in the House today to recognize Mr. Mark Brown of

Windsor Lake who was recently honoured by United Way.

In 2002,

Mark started his work to establish a

chapter of United Way in our great

province. In 2005, United Way of Avalon was launched and then became United Way

of Newfoundland and Labrador in 2009.

Mark has

dedicated the last 15 years to United Way in many forms. He was the founding

chair, is a member of the past chairs council and now his volunteer work has

been recognized by the establishment of the Mark Brown Community Builder Award.

This

Community Builder Award recognizes an individual who works to build stronger,

more resilient communities through volunteering with United Way.

As a

member as the past chair advisory council, I'm confident that Mark is excited to

see United Way grow and create an even greater impact in our communities.

Thank

you, Mark, for all your hard work to such a great organization.

As Mark

would say: “Each of us has something to offer. Every little bit counts.”

Mark,

we're so grateful for your efforts.

Thank

you.

SOME HON. MEMBERS:

Hear, hear!

MR. SPEAKER:

The hon. the Member for

Lewisporte – Twillingate.

MR. D. BENNETT:

Thank you, Mr. Speaker.

I rise

in this hon. House to recognize a good friend and an award winning

singer-songwriter from Lewisporte, Mr. Terry Penney.

Terry's

accomplishments encompass multiple Music NL awards, including Male Artist of the

Year, Songwriter of the Year and two-time Country Artist of the Year. Terry has

also received recognition on the national and international music scene for his

outstanding work.

Terry

has captivated audiences from England, Ireland, the United States and various

parts of Canada. Through his song writing and performances, Penney has given a

strong voice to Newfoundland and Labrador war veterans since the release of

“Normandy in Newfoundland” in 2002. Since that time, he has released several

critically acclaimed songs inspired by our veterans.

November 3, I had the honour of attending Terry's eighth CD release,

The Unforgotten: Stories of Newfoundland

Veterans , which featured a literary collection of short stories, song

lyrics, interesting facts and wartime photographs, as well as a full-length CD,

featuring nine war-related songs written by Penney.

Mr.

Speaker, I ask all Members to join me in congratulating Terry Penney on his past

accomplishments and wish him much success in his future endeavours.

Thank

you.

SOME HON. MEMBERS:

Hear, hear!

MR. SPEAKER:

The hon. the Member for Fogo

Island – Cape Freels.

MR. BRAGG:

Thank you, Mr. Speaker.

Today I

rise in this hon. House to highlight a milestone upcoming for a senior and her

family from my District of Fogo Island – Cape Freels.

Leah

Ackerman was born in Pound Cove, Bonavista Bay, on November 23, 1917. She was

one of eight children born to the family of Spencer and Beatrice Green. At the

age of 16, she travelled to St. John's where she found employment working as a

nanny for a family on Shaw Street.

Four

years later, she returned home for the Christmas holidays where she met her

future husband, Elisha Ackerman. They married on March 10, 1938 and moved to

Wareham. Together they had 12 children and, from that, 25 grandchildren, 45

great-grandchildren and nine great-great-grandchildren.

Back in

the day, Mrs. Ackerman held the highest level of education in the community.

During the Second World War, mothers and wives would drop by her house to have

letters from loved ones read. Mrs. Ackerman is known for her generosity, opening

her door to many over the years.

Please

join me in wishing Mrs. Leah Ackerman a very happy 100th birthday.

Thank

you, Mr. Speaker.

SOME HON. MEMBERS:

Hear, hear!

MR. SPEAKER:

The hon. the Member for

Conception Bay East – Bell Island.

MR. BRAZIL:

Thank you, Mr. Speaker.

I stand

today to recognize the passing of a very valuable educator and volunteer in my

district. I speak of the recent passing of Mrs. Joan (Craig) Whelan of Bell

Island.

Joan had

served as a volunteer with a number of organizations over her 77 years, but it

is her contribution to education on Bell Island where she made her biggest mark.

Her nearly three decades as a teacher in the mainstream school system played an

important role in mentoring and guiding hundreds of young students. Her advocacy

for those who could not advocate for themselves, particularly those who needed

an alternate approach to education and social inclusion, is a true testament to

her commitment to her community.

As the

founding member and the volunteer coordinator of Operation Sunshine for the past

decade, she improved the quality of life for a number of special needs adults

while providing services to the Janeway's Neonatal Unit, the Boys and Girls Club

and numerous other organizations.

Her

energy and enthusiasm never faltered, even though Joan lived most of her life

with physical limitations. Her dedication and commitment to her community will

be missed.

Rest in

peace, Joan.

Thank

you, Mr. Speaker.

SOME HON. MEMBERS:

Hear, hear!

MR. SPEAKER:

The hon. the Member for

Placentia West – Bellevue.

MR. BROWNE:

Mr. Speaker, I rise today to

recognize the honourable Mr. Vikas Khaladkar, a newly appointed Justice of the

Supreme Court of Newfoundland and Labrador.

Justice

Khaladkar's professional resume is extensive and impressive. From appearing as

co-counsel before the Supreme Court of Canada on a case which solidified the

rights to provide persons detained or arrested with right to counsel, to serving

as chair of the Project Management Team for the construction of the First

Nations University of Regina Campus, to prosecuting MHAs as the Crown Attorney

in the aftermath of the House of Assembly spending scandal.

His

legal credentials are self-evident and his sense of justice is unshakable, but

so too is his sense of community. As a resident of Sunnyside in my District of

Placentia West – Bellevue, he became dedicated to the Heritage Committee and was

always someone Mayor Snook felt the town could rely on. He also became known for

his talented photography. In fact, one of his photos of the Hebron GBS at Bull

Arm still hangs in my office today.

Mr.

Speaker, I ask all hon.