Monitoring programs for drugs with potential for abuse or misuse in Canada

Introduction

The compliance and monitoring of controlled substances in Canada are regulated by Health Canada's Controlled Drugs and Substances Act. The Controlled Drugs and Substances Act (CDSA) was passed in 1996 to replace The Narcotic Control Act and Food and Drugs Act, Parts III and IV. It establishes 8 schedules of controlled substances and 2 classes of precursors. While the importation, production, distribution and possession of various drugs and substances in Canada are governed primarily by the provisions of the CDSA, it does not regulate or monitor the prescribing of narcotics or controlled substances. At present in Canada, there are no national monitoring or comprehensive surveillance systems in place to identify, monitor, record and track the diversion, abuse and misuse of narcotics or controlled substances. As a result, individual provinces have established prescription monitoring programs to promote the appropriate use of certain monitored drugs with the potential for abuse, misuse and diversion for nonmedical purposes. Currently, in Canada, there are 7 monitoring programs, with 1 program in development. The goal is to reduce the abuse or misuse of monitored drugs in these provinces. The objective of this paper is to provide a summary of the drug monitoring programs available in Canada, the review process to include or exclude drugs in the program and program evaluation for outcomes.

Methods

Initially, a MEDLINE search, limited to the years between 1990 and the present, was done using MeSH and PubMed terms “prescription monitoring program,” “triplicate prescription program” and “monitoring controlled substances,” as well as all the individual provinces and territories, in combinations with AND and OR delimiters. This search did not yield any results. A similar search of The Cochrane Library, IPA and EMBASE did not reveal any results, either. As no published information was found in the literature, we contacted individual provincial prescription monitoring programs for information. Drug monographs and drug policies within each jurisdiction were also used to help gather information. The following is a summary of all the prescription monitoring programs in Canada. Each province or territory, with the exceptions of Prince Edward Island, Yukon and the Northwest Territories, has its own monitoring program.

Drug monitoring programs in Canada

British Columbia: Controlled Prescription Program/Prescription Review Program (PRP)

The PRP is designed and administered by the College of Physicians and Surgeons of British Columbia to encourage proper opioid prescribing.1 The PRP is a peer review program of the College of Physicians and Surgeons of BC to review physician prescribing of controlled substances. The main goal is to provide education to providers, not discipline.

The Controlled Prescription Program, which replaced the triplicate prescription program, monitors the appropriate use of high-risk controlled drugs that require a duplicate prescription. The College also has access to PharmaNet, a database that can provide real-time information on all controlled substances prescribed in BC.

Alberta: Triplicate Prescription Program (TPP)

The Alberta TPP was introduced in 1986 with the intent to monitor prescriptions drugs that have abuse, misuse and diversion potential.2 It began as a collaborative, multidisciplinary program that included the College of Physicians and Surgeons of Alberta, Alberta College of Pharmacists, Alberta Dental Association and the Alberta Veterinary Medical Association. Currently, the College of Physicians and Surgeons of Alberta is the administrator of the program.

At present time, there are no specific criteria for inclusion or exclusion of drugs for the program. Each drug is reviewed based on published evidence presented by a steering committee.2 In order for a drug to be included under the TPP, evidence must be presented that supports the potential for its abuse. Conversely, for exclusion from the TPP, evidence must support low abuse potential for the drug in question.2,3 A drug may be reviewed for inclusion or exclusion at any time.

Triplicate prescription pads, used only for drugs identified by the program as being at risk for abuse, misuse and diversion, are supplied only to authorized physicians to minimize the likelihood of prescription forgery or alterations due to the uniqueness of the prescription pads and limited number of prescribers. A copy of the written triplicate prescription is collected by The College of Physicians and Surgeons for review of prescribing patterns of monitored drugs, in order to identify abuses such as patients seeking monitored drugs from multiple physicians or physicians prescribing inappropriate quantities. Physicians identified as prescribing inappropriately are reviewed by the College and may have their authority to prescribe these medications revoked.

Yukon: Triplicate Prescription Program (TPP).

The Yukon Territory shares its TPP with Alberta.

Saskatchewan: Prescription Review Program (PRP)4 The Saskatchewan PRP is administered by the College of Physicians and Surgeons of Saskatchewan (CPSS). The intent of the Saskatchewan PRP is to reduce the abuse and diversion of a select panel of prescription drugs. The list of drugs monitored by the PRP is based on current abuse and abuse potential in Saskatchewan (Doug Spitzer, College of Physicians and Surgeons of Saskatchewan, personal communication, August 2010). In order to add a drug to the PRP, supporting evidence must be submitted to the Saskatchewan Health Review Committee.4 The Saskatchewan Health review committee represents the government of Saskatchewan. The CPSS also audits the inappropriate use of approved drugs.

Prescribers do not need to use a special prescription pad for drugs under this program. The program monitors use of designated drugs to detect inappropriate use by patients or inappropriate prescribing practices. Prescribing physicians are alerted by CPSS about their prescribing practices.

Manitoba: Manitoba Prescribing Practices Program (M3P)

This program, formerly known as the Multiple Prescription Program and the Triplicate Prescription Program, was put in place to minimize drug diversion of controlled and narcotic medications. Currently, the M3P is being managed by the Manitoba Pharmaceutical Association (MPhA). The goal of Manitoba's M3P is to promote appropriate prescribing of certain narcotics and controlled drugs and to decrease diversion of these medications.5 All sales-reportable narcotics and controlled drugs are included in the M3P.6 Both amphetamines and their derivatives are sales reportable in Manitoba. The M3P does not have a defined set of criteria for the inclusion or exclusion of drugs at this time. The review system is similar to the Alberta program. Upon review, evidence must be presented to an ad hoc committee for evaluation.

Newfoundland: Tamper Resistant Prescription Drug Pad Program

The purpose of the Tamper Resistant Prescription Drug Pad Program (TRPP) is to reduce prescription drug abuse and diversion by reducing the likelihood of prescription forgeries and/or alterations due to the uniqueness of the prescription pads.7 The TRPP is, however, not a monitoring program (Don Rowe, Newfoundland and Labrador Pharmacy Board, personal communication, August 2010). The TRPP does not have specific criteria for the inclusion or exclusion of medications to be included in the program. The Newfoundland Provincial Department of Health is responsible for setting the TRPP list of drugs and consults the Newfoundland and Labrador Pharmacy Board and the College of Physicians and Surgeons of Newfoundland and Labrador regarding any changes to inclusion or exclusions to the scheduling (Patricia Clarke, Newfoundland Department of Health, personal communication, August 2010).

Nova Scotia: Nova Scotia Prescription Monitoring Program (NSPMP)8

The Prescription Monitoring Association of Nova Scotia (PMANS) was founded in October 1991 to monitor the prescribing and dispensing of specific narcotic and controlled drugs in Nova Scotia through the use of a triplicate prescription pad, with the goal of reducing the misuse and abuse of these agents.

The Nova Scotia Prescription Monitoring Program (NSPMP) was instituted in 2005 to replace PMANS. The NSPMP is responsible for the review of evidence of specific drugs for inclusion or exclusion in the program. Amendments to the regulations are legislated by the government of Nova Scotia based on the recommendations of NSPMP (Denise Pellerin, Nova Scotia Prescription Monitoring Program, personal communication, August 2010).

The NSPMP monitors drugs included under the Controlled Drug and Substances Act of Canada, with the exception of topical testosterone and benzodiazepines. Between 2004 and 2007, all monitored drugs were prescribed using a triplicate prescription pad and copies were manually submitted to the monitoring program. In 2007, the process was changed so that all submissions to the NSPMP were performed online, however, monitored drugs must still be written on triplicate prescription pads.

Programs in development

Ontario Narcotics Strategy9

In response to the increasing abuse of prescription narcotics and controlled substances, the Ontario government launched a new Ontario Narcotics Strategy on November 1, 2011. The province tracks prescriptions through a new database designed to identify unusual patterns of prescribing and dispensing. In addition, the program provides educational support and resources for prescribers, dispensers and patients. This program also provides treatment for patients with addiction.

New Brunswick10

The province of New Brunswick is working to develop an online program to allow pharmacists to view a patient history of narcotics and controlled drug in real time before dispensing a monitored drug. The program is supported by a stakeholders working group that includes the New Brunswick Medical Society, New Brunswick College of Physicians and Surgeons, New Brunswick Pharmacists' Association and New Brunswick Pharmaceutical Society. The program was planned to be implemented in early 2011; however, it has been delayed.

Monitoring summary

All existing programs except those of Saskatchewan, BC and Alberta monitor drugs based on the federal drug schedules. While there are no known formal evaluations of the effectiveness of the provincial initiatives outlined above in reducing the misuse/abuse of monitored drugs, there is some evidence that they are working. As multiple doctoring is common in a medication misuse/abuse situation, the number of physicians prescribing monitored drugs for a single patient can be used as a surrogate marker for abuse, bearing in mind that a patient may have several prescribers for a legitimate reason (post-surgery, no family physician, residents in a tertiary care setting, etc.). The 2009/10 Annual Report for the Nova Scotia Prescription Monitoring Program showed positive results using physician notifications for patients suspected of misuse/abuse due to double doctoring. In the 3 months following notifications to involved physicians, there was a 44.3% decrease in the average number of prescribers per patient.11 By being able to identify patients who might be involved in misuse and abuse of monitored medications using the surrogate marker of number of involved physicians, they were able to help cut down the potential for abuse by making the prescribers aware and allowing the prescribing of monitored drugs to be concentrated to one physician. This is a step in the right direction in the field of drugs of misuse and abuse.

There are issues and challenges associated with the monitoring programs. The monitoring programs could potentially affect the quality of care in patients who have legitimate reasons for the use of monitored drugs, such as those requiring palliative care or cancer pain control. Physicians may become reluctant to prescribe closely monitored drugs and may reduce or alter their prescribing behaviours. For example, it has been suggested that physicians may choose to prescribe less appropriate medications to avoid raising attention and potential auditing and scrutiny by colleges of medicine and other governing bodies. The other challenge associated with the monitored programs is the operational cost. The Alberta program costs about $600,000 to $700,000 per year to operate. About 80% is funded by the provincial government. Almost 50% covers the annual cost of triplicate prescription pads.

Conclusion

It is clear that a comprehensive and consistent national electronic prescription monitoring system is needed in Canada in order to minimize or eliminate misuse/abuse of monitoring drugs. Ultimately, an integrated, collaborative effort among all health care professionals and regulators is crucial to successfully promote appropriate use of controlled substances and minimize the misuse/abuse and diversion of monitored drugs.