Campaign for a National Drug Plan-Not everyone has drug coverage

Your drug plan at work …
and why we need pharmacare

Half the Canadian population — 16 million people — are covered by drug plans through the
work place. These work-based plans cover both employees and their dependents, and go some
way to filling in the biggest gap in Canada’s healthcare system — its lack of a national
pharmacare plan. But as medications become an increasingly important part of treatment for
many conditions, and their costs rise, this employee-benefit approach to insuring drug costs is
proving inadequate.

How good is this drug coverage?

It varies.Most drug plans at work are negotiated by unions for their members. In the best plans, the insurance premiums are paid by the employer and drugs are fully covered by the insurance
plan. But that model is rare. More than half of all workers contribute to the cost of the
insurance premiums through deductions from their wages. On top of that, most plans pay only
part of the cost of prescriptions, because of deductibles. Most workers pay a set amount
(usually about $50 or $75 per family member per year), before the insurance kicks in. A lot of
plans also require the worker to pay a percentage of the cost of each prescription — for
example, the drug plan may cover 80 per cent of the cost, and the worker pays the other 20 per
cent of every prescription.

Drug coverage is based on where you work, not medical need.

The benefits provided in negotiated collective agreements reflect a whole range of factors, like
the strength of the union, the state of the industry and the finances of the employer. None of
that has anything to do with people’s need for prescription drugs.
Work-based drug coverage is not secure.

If you move away, find a different job or get laid off, you lose your drug plan. In most cases
retirees are not covered, so if you retire, you also lose your drug plan. And when workers lose
drug coverage, so do their family members. Of the 16 million covered by work place plans, 7.6
million are workers, 4 million are their adult family members and another 4.4 million are their
children.

PUBLIC, ACCESSIBLE, AFFORDABLE, SAFE AND APPROPRIATE

Campaign for a National Drug Plan
Not everyone has a drug plan at work.
Almost half of Canadians (42 per cent in 2000) are not covered by work place drug plans.
Part-time workers and young people are less likely to have drug coverage and smaller work
places may find it too expensive to get a drug plan because insurance companies charge a much
higher administrative fee to cover small numbers of workers. Some workers who don’t have
their own drug plan are covered by their spouse’s plan, but many have no drug insurance.
Work-based drug plans are under threat.
Drug costs are rising rapidly, so insurance premiums are getting more expensive. Employers
looking for ways to cut their costs may react by increasing the share paid by workers or
reducing the coverage. Workers find themselves paying more for their premiums and more at
the pharmacy counter. This is leading to conflict at the bargaining table and strikes, as workers
struggle to protect their benefits.

We can do better than this.

Drug insurance based in the work place covers some people, some of the time. But it is limited,
arbitrary and insecure. It is a patchwork system — not based on need, but on where you work
or where your spouse works. Nearly every other industrialized country covers prescription
drugs under their public health care plan, and Canada should do the same.

We need pharmacare, a national drug plan.

Drugs are an integral part of health care and should be part of Medicare. A universal public
plan would provide equal drug coverage no matter where you live or work. It would be far less
expensive to administer than the thousands of different work-based plans and would have the
negotiating strength to bargain for cheaper prices with the drug companies. It makes medical
and financial sense to provide drugs to people who need them through a public system, not
haphazardly through the work place.

For more information, read the full report:

More for Less: A National Pharmacare Strategy (www.healthcoalition.ca/moreforless.pdf)

About the Campaign for a National Drug Plan
Pharmacare means a national drug plan that would be publicly funded and administered,
control costs, provide universal access and ensure the safe and appropriate use of drugs. It would cover medically necessary drug costs in the same way that Medicare now covers hospitals and physicians. The Canadian Health Coalition is a public advocacy organization dedicated to the
preservation and improvement of Medicare. For more information visit: www.medicare.ca

Myths about Narcotics and Cancer Pain Control

Myths about Narcotics and Cancer Pain ControlBack to the Table of Contents

A lot of cancer patients want to avoid taking opioids. Many fear that they will become addicted to these medications, and some feel that narcotics should be used only as a last resort for fear that they will not be effective when they are really needed. Doctors may also share some of the myths about opioid medications. These myths form barriers to good and effective relief of cancer pain. These myths need to be understood and addressed by patients and their caregivers.
Myth 1. People given opioids for pain control are always doing worse or are near death.
Just because a person is placed on a narcotic does not mean that he or she is gravely ill. Opioids are highly effective medications that can be used at any stage in the disease when severe pain requires strong medication.

Myth 2. All patients getting morphine or other opioids will become addicts.
Addiction is a psychological need for a drug and rarely, if ever, develops in people using narcotics for pain control. Physical dependence, however, always occurs in patients taking narcotics for a long time. Physical dependence is a problem only when a patient is suddenly taken off the drug. If this happens, a physical reaction, called withdrawal syndrome, takes place. If a disease becomes cured during therapy and opioid medications are no longer needed, they can be withdrawn slowly so that the withdrawal syndrome does not develop. (However, sometimes chronic opioid medications are still needed, because of the previous tissue destruction that the tumor or therapy caused.) The bottom line is that physical dependence does not equal addiction.

Myth 3. Patients who take opioid medications develop tolerance and always need more and more medicine.
There are many reasons behind the need for increased doses of an opioid medication. One is spreading disease or a change in the type of pain, such as a new neuropathic pain problem developing with tumor spread. Another reason is tolerance, which means the need for an increasing dose of a drug in order to achieve a desired result. Tolerance, if it develops at all, does not develop suddenly, and doctors can respond to its development by increasing the dose. Opioid medications are safe even at very high doses if given correctly. If a patient no longer experiences pain relief at one dose level, the dose can be safely increased again and again.

Myth 4. Opioids are dangerous because they can make breathing harder for a terminally ill patient.

Morphine and other opioid drugs are not dangerous respiratory depressants in patients with cancer and pain. Doses are gradually increased and tolerance to the respiratory-depressant effects of these drugs usually develops before tolerance to their pain-relieving effects.

Myth 5. People taking opioids must get it by injection since opioids are poorly absorbed by mouth.

Most opioids are absorbed very well when taken orally. However, a fair amount of the dose taken by mouth is ``lost'' to nontarget body tissues and therefore wasted, so larger dosages of the drug are required than the doses needed for shots. The pain equivalency between oral and intramuscular (shots) or intravenous morphine is 3 to 1 when taken over time, meaning that 30 mg of oral morphine is equivalent to 10 mg of intramuscular or intravenous morphine.

Treatment Plan for PainBack to the Table of Contents

Treating and controlling pain is a primary concern for all members of the health care team, including your doctors, nurses and the hospital and home care team. According to the World Health Organization committee on cancer pain, 90 to 95 percent of all cancer pain can be well controlled using a special set of guidelines. These guidelines separate pain into levels of intensity and suggest tailoring the strength and potency of prescribed pain-relieving medications to the intensity. Not all cancer pain requires strong narcotics. But strong pain requires strong medications.

The guidelines suggest that mild pain be treated with nonnarcotic medications such as aspirin, acetaminophen (Tylenol) or other aspirin-like drugs called nonsteroidal anti-inflammatory drugs (NSAIDs);
moderate pain be treated with a combination of NSAIDs and weak narcotics such as codeine (Tylenol with codeine), hydrocodone (Vicodin or Lortab), Percocet, Percodan or propoxyphene (Darvon), and
severe pain be treated with strong opioids such as morphine, Demerol, Dilaudid, fentanyl (duragesic patches) or methadone in combination with an NSAID.
The guidelines also suggest adding an adjuvant medication to these narcotic and nonnarcotic medications when appropriate. These medications--which include steroids, bone-forming, antidepressant and anticonvulsant medications, antihistamines and sedatives--are often useful in treating opioid-resistant pain. For whatever reason, they do relieve pain, although they are not usually labeled as pain relievers.

Simple measures such as aspirin or Tylenol, with or without codeine, or ibuprofen may do the job well enough. But when pain is severe, the dosage has to be increased or the drug has to be taken more frequently. If these simple measures don't help, then it is important to increase the strength or potency of the medication. Sometimes, just the addition of an adjuvant medication is all that is needed.

Side Effects of Pain MedicationsBack to the Table of Contents
Not all people tolerate all drugs equally. Some people are allergic to various medications. Some develop side effects from medications that others taking the same drugs do not share. Some people tolerate one specific drug in a class of drugs but do not tolerate others in the same class. Some do not tolerate any drugs in a particular class. Everyone is an individual.
While 90 to 95 percent of patients receive adequate pain control using the WHO guidelines, there are still 5 to 10 percent of patients who do not achieve adequate pain control. Certain direct interventions by specialists can modify or block pain information from reaching the central nervous system.

These interventions include nerve blocks with local anesthetics or nerve-destroying agents, alternative delivery systems such as administering narcotics under the skin (subcutaneous) or into the spine, spinal local anesthetics or other therapies that destroy nerves causing the pain.

These invasive, interventional therapies require the expertise and skills of a pain specialist. Morphine remains the gold standard of medical practice. Morphine and other options can be taken in a variety of ways. Most methods control pain very effectively.

PainBack to the Table of Contents

Many patients with cancer fear that they will suffer pain. In fact, at some point during the course of the disease, 60 to 90 percent of patients will require a pain-relieving therapy. But not all cancers produce pain equally, and some cancers, even when advanced, may not cause pain at all. Cancers that are more typically painful include tumors of the bone (either primary or through spread) and the organs of the abdomen. Cancers of the blood system, such as leukemias or lymphomas, often never cause pain.

Pain can have a terrible effect on a cancer patient's life. It can lead to depression, loss of appetite, irritability, and withdrawal from social interaction, anger, loss of sleep and an inability to cope. If uncontrolled, pain can destroy relationships with loved ones and the will to live. Fortunately, pain can almost always be controlled. What is needed is an understanding by caregivers of the nature of the pain, of what causes it and of the appropriate treatments for the type of pain involved, as well as a commitment to relieving it. The oncologist is usually well equipped to handle most types of pain. For more unremitting pains, patients may be referred by their doctor to a specialist who will help to sort out the cause and treatments for symptoms.
Pain is a complex phenomenon. It has physical, emotional and psychological components. How each person responds to pain is also complex.

The extent of disease and the nature of the discomfort contribute to a person's experience of pain. But pain is also modified by remembrances of past painful episodes, the special meaning of pain to each individual, the expectations of family and friends, religious upbringing and personal coping skills and strategies. Cultural beliefs also influence the pain experience. Certain cultures teach tolerance of pain or that the outward expression of pain is inappropriate. People from these cultures bear their pain without complaining or even expressing their needs. Externally, they may appear to have a higher threshold or tolerance to pain while in fact suffering quietly. Other cultures readily and outwardly express painful experiences, and people from those cultures may appear to have a lower threshold or tolerance.Types of PainBack to the Table of Contents
Somatic Pain from the cancer itself may come from a bone broken because of tumor invasion or from an obstruction in the intestine or urinary tract. Pain from bone involvement is often described as achy, dull, localized and brought about by activity of the surrounding muscle groups or movement of the limb or spine. Obstructions in the intestine or urinary tract typically are described as crampy and more diffuse. They may be associated with inability to eat or to pass stool or urine.

Neuropathic Pain from nerve involvement is either related to direct tumor spread, such as the spread of colon cancer into the pelvis where the nerves to the legs or pelvic structures reside, or is secondary to irritating substances that tumors secrete near nerves. Neuropathic pain may also result from pressure on the nerves, as when spinal tumors pinch or press on nerves to the arms or legs. Neuropathic pain is often described as sharp, burning, electrical, shooting or buzzing. It typically occurs in the area that the injured nerves serve.
Surgery may cause both somatic and neuropathic pain. Pain from direct surgical injury is somatic and usually responds to opioid medications. Surgical injury to nerves may respond to opioids, antiseizure or antidepressant medications.

Chemotherapeutic drugs act like poisons to tumors and may act the same way on some vulnerable nerves. Drugs such as antiviral agents or vincristine, cisplatin, carboplatin, Taxol and Navelbine can cause peripheral neuropathy, which is often felt as a burning in the hands and feet. This requires drugs specific for neuropathic pain or some other intervention for relief. The sore mouth (mucositis) that is sometimes a side effect of these drugs is one example of somatic pain from chemotherapy.

After radiation therapy, pain may be due to skin reactions to the radiation, breakdown of mucous membranes or even scarring of the nerves (fibrosis), which can produce a neuropathic pain.

Emotional SourcesBack to the Table of Contents
Pain is made worse by worry and fear of death, suffering, deformity, financial disability or isolation. The onset of pain or a new pain may trigger fears about the spread of the disease or of impending death. All these fears can be magnified when a kind of spiritual pain accompanies the fear. This might be triggered by surroundings, low levels of emotional support or feelings of loneliness and desperation. How one approaches the problems of life makes a big difference to the perception of pain. Also, whether pain is adequately controlled makes a big difference.

What is pharmacist prescribing?

What is pharmacist prescribing?

Prescribing by pharmacists differs from what is currently understood as prescribing by other health professions.

Pharmacist prescribing describes a wide range of activities. It includes:
prescribing drugs to treat minor, self-diagnosed or self-limiting disease conditions;
adjusting dosages and dosage forms;
monitoring and refilling prescriptions to ensure appropriate and effective care;
providing emergency supplies of previously prescribed medication;
providing comprehensive drug therapy management where the pharmacist, working with other health professionals, takes full responsibility for establishing and maintaining a patient’s chronic drug therapy; and
substituting another drug that is expected to have a similar therapeutic effect.

Pharmacists will assess and triage each patient as required. If the pharmacist has the competencies and appropriate information to initiate drug therapy for minor, self-limiting or self-diagnosed conditions, he or she may initiate treatment. Alternatively, the pharmacist may refer the patient to another part of the health system.

What kinds of prescribing can pharmacists do?

Prescribing activities can be grouped into three general categories:
initial access prescribing—prescribing when a patient chooses a pharmacist for advice about and treatment of minor, self-limiting or self-diagnosed conditions, about wellness programs, or in urgent or emergency situations
prescription modification—modifying a prescription written by another prescriber to alter dosage, formulation, regimen or duration of the prescribed drug, or provide a therapeutic alternative to improve drug therapy or provide continuity of therapy
comprehensive drug therapy management—initiating, maintaining, modifying or changing drug therapy based on referral from another health provider who has made the diagnosis or upon the request of the patient upon receiving a diagnosis. Comprehensive drug therapy management will occur only in a collaborative health team environment wherein sufficient information is available to the pharmacist for him or her to make a recommendation for drug therapy.

What issues will affect how or if a pharmacist prescribes?

Pharmacists prescribing is dependent on good communication between the pharmacist, the patient, and the other health professionals on the patient's health care team. Patient health and safety always come first.

Only pharmacists on the clinical register (a new registration category under the Health Professions Act) are eligible to prescribe.

All pharmacists on the clinical register are required to participate in an orientation program designed by the Alberta College of Pharmacists (ACP)before exercising prescribing privileges.
Each pharmacist must limit their prescribing to their areas of professional competence.

Pharmacists must meet additional specific criteria set by the college to be authorized to initiate new drug therapy and/or to manage ongoing therapy.
Pharmacists will only prescribe if they have sufficient information to make decisions on safe and effective drug therapy.
For more details on pharmacist prescribing, see Patient information sheet

Whats a Nurse practitioner anyway?-Doctor to busy and need to be seen now

Why aren't we producing and employing "hoards" of Nurse Practitioner in Canada to cover speciality practice areas such as anesthesia (the vast majority of all anesthesia in USA is administered by NP's), Family Practice etc. What a great complement to extend the health and medical services. Nurse practitioners are vastly under utilized and underemployed in Canada due to "turf" resistance from Doctors.

Imagine this: your child's fever is soaring, but the doctor's schedule is completely booked. The receptionist tells you that a nurse practitioner is available to see your child. Although you don't know much about nurse practitioners, you set up an appointment.
This is the way many parents have discovered that nurse practitioners (NPs) provide excellent care for their infants, children, and teenagers. Recent studies show that in some respects, these trained specialists deliver the same — or better — care as medical doctors.

Here is how NP's practice in the USA:

More About Nurse PractitionersNPs take health histories and provide complete physical examinations, diagnose and treat many common acute and chronic problems, interpret laboratory results and X-rays, prescribe and manage medications and other therapies, provide health teaching and counseling to support healthy lifestyle behaviors and prevent illness, and refer patients to other health professionals as needed.
An NP provides high-quality, cost-effective and individualized care for patients, families and communities. NPs are authorized to practice across the nation and have privileges to prescribe medications, in varying degrees in all 50 states.

What's an NP?

A nurse practitioner is a registered nurse (RN) who has additional education and training in a specialty area such as family practice or pediatrics.

Nurse practitioners (also referred to as advanced practice nurses, or APNs) have a master's degree in nursing (MS or MSN) and board certification in their specialty. For example, a pediatric NP has advanced education, skills, and training in caring for infants, children, and teens.

Licensed as nurse practitioners and registered nurses, NPs follow the rules and regulations of the Nurse Practice Act of the state where they work. If accredited through the national board exam, the NP will have an additional credential such as Certified Pediatric Nurse Practitioner (CPNP) or Certified Family Nurse Practitioner (CFNP).

Pediatric and family practice NPs can provide regular health care for kids. An NP who specializes in pediatrics can:
document health history and perform a physical exam
plan a child's care with parents and the child's health care team
perform some tests and procedures
answer questions about health problems
treat common childhood illnesses
change the plan of care with a child's doctor as needed
teach families about the effects of illness on a child's growth and development
teach kids about self-care and healthy lifestyle choices
write prescriptions
order medical tests
teach other health care members and local groups about child health care
provide referrals to community groups
NPs and Doctors
NPs work closely with doctors to provide individualized care for their patients. NPs are licensed in all 50 states, and can dispense most medications. A few states require a doctor to co-sign prescriptions.
Although doctors have additional training to help patients deal with complex medical problems, many people think NPs may spend more time with their patients. Experts who study NPs report that their training emphasizes disease prevention, reduction of health risks, and thorough patient education.
Like doctors, NPs are involved in more than just direct patient care. Many participate in education, research, and legislative activities to improve the quality of health care in the United States.

Should My Child See a Nurse Practitioner?

Pediatric NPs are capable of delivering much of the health care that kids require, consulting doctors and specialists when necessary. Educating the child and the family about the normal growth and development issues that arise in childhood (i.e., toilet training, temper tantrums, and biting) is a large part of the pediatric NP's role. They also take the time to talk to families about issues that might be considered routine, but that can make the difference between a pleasant office visit and one that's stressful.
Pediatric and family practice NPs can treat acute (or short-term) illnesses such as upper respiratory infections, ear infections, rashes, and urinary tract infections. They can also assist with management of chronic illnesses such as asthma, allergies, diabetes, and many others that affect children.

If your child has severe health problems that require advanced training or highly specialized medical care, you may need to seek the care of a doctor. If you're unsure about your child's specific illness and want to know if an NP can help, ask your doctor. The scope of an NP's practice depends upon your state's regulations.

If you want to verify an NP's credentials, check with the American College of Nurse Practitioners (ACNP). It's also a good idea to ask NPs about their specific qualifications, education, and training, just as you would interview a prospective doctor for your child.
Also be sure to check with your health insurance provider to ensure that services provided by NPs are covered through your policy.

In addition, many doctors share office space with NPs to provide all types of primary care. Other doctors work with NPs to offer them training in different types of health care. Your doctor might already have such an arrangement in place, so just ask.

Reduce health care wait times-health care reform

How To improve health care through collaborative practice? Why wait for a family doctor when you can see a Nurse Practitioner for common illness and medical issues or a pharmacist for routine refills. Much of the system is weighed down by Doctors demanding more visits from their patients than is really needed. For example routine refills of common medications, make an appointment to review blood work rather than on the phone etc. Other health care providers can easily fill the gap and strengthen the system.

A tour of different facilities in Canada will show how wait lists can be eliminated.
In southwestern Saskatchewan, one physician working in a team with three nurse practitioners looks after 3,200 patients, over twice the Canadian average.

In Hamilton, Ont., teams of mental health counsellors, family doctors and psychiatrists have increased the numbers of patients treated for mental health problems by 900% while decreasing referrals to the regional psychiatry clinic by 70%.

In Sault Ste. Marie, Ont., a task force reduced the time from mammogram to breast cancer diagnosis from 107 to 18 days.
The list goes on. We need to focus on making these innovations the new norm in health care delivery.
Linda Silas, president, Canadian Federation of Nurses Unions, Ottawa.

Improper Healthcare Utilization is a driving up costs and your taxes

As mentioned in the previous blog, health care utilization is a far greater cost driver than many other factors. For example, a family physician writes a prescription for Celebrex for a patient with aches and pains. The patient is over 65 and on the Ontario Drug Benefit program so the drug is paid for. The patient is also on 81mg Aspirin to prevent heart attack. The protective effect and main reason for prescribing Celebrex is no lost.

Yet, our drug plan stills pays $1.37 per pill for the Celebrex. Why? A simple prescription of Naproxen or similar anti-inflamatory would be perfectly suitable and as safe for only 21 cents a pill! Whats going on? There are many examples of such blatant utilization abuses within our system costing millions of your dollars.

The reason it is prescribed is mainly because the sales representative from the drug company had just finished taking the precriber out to dinner and you the tax payer are paying for it!

Whats really driving up our health care costs?

The real cost driver in our Canadian health care system is the blank slate health care professionals especially physicians have in determining therapeutic options for you. For example, is the most expensive drug on the market needed to treat some conditions or will a suitable generic substitute be more cost effective and achieve the same goals?

The physician receives a "spiff" from the patented drug company to prescribe certain medications. The patient comes in with a common condition and is prescribed a drug that the drug company has paid the physician to write. Many times uninsured patients will not be able to afford the medication prescribed when a lower cost alternative is available. Is this good medical practice?

So utilization is more of a cost driver than pure medication costs. Physicians should not just be allowed to prescribe a range of very expensive options or theraputic interchange at the pharmacy level should be permitted. Drug utilization needs to become a reality for most common conditions. The extra money could be re-cycled in the healthcare system to retain physcians and train more health care professionals.

Nurse Practitioners and certified pharmacists should be able to prescribe and treat common conditions to free-up physicians to manage complex conditions and our geriatric patients. Physcians should be duly compensated for their efforts. Healthcare professionals, including Doctors, should work within a new collabortive model similiar to the United Kingdom. One of the main reasons for the expensive and labourious system we have now is because physicians are simply "protecting their turf" at the expense of our health system and patients. Canadians deserve better.

Vote for strong willed politions to save our health care system and stand-up to the medical lobby.