Distinct Prescribing in Quebec: a distinction we could do without

Spending determinants

Canadian cash

Pharmaceutical companies and drug authorities are too discreet in Canada and Quebec when it comes to breaking down consumer spending in retail pharmacies for prescription drugs. The third edition of the Canadian Drug Atlas by Morgan et al. is a unique source that revealed provincial differences in spending in 2012-2013 [1]: Ours was 30% above the national average on all prescription drugs and this trend is unlikely to have changed significantly in the past five years, because prescribing habits are always difficult to change, especially when it is necessary to “deprescribe” in a patient, an art that requires courage and skill.

The per capita annual expenditure has several determinants stemming from the prescribers: the prescribed volume (number of prescriptions x amount of units per prescription) and the choice of particular products. It is indeed more costly to prescribe still patented versions, or new specialty drugs, than to use generics that clinicians have learned to handle.

Other factors are the selling price per unit (related to manufacturer, wholesaler and pharmacy owner), the pharmacists’ fees and the reimbursement rate. Quebec’s Drug as well as Pharmacy policies prevailing at the time of the survey were not unrelated to higher spending in our province.

Quebec by comparison

Exceedances relative to the Canadian average are presented in percentages adjusted for age in the Canadian Atlas. The average pharmacy expenditure was $656 per person, for a national total of $22.9 billion. Quebec led the provinces with $821 per person.

If “less is more” in prescribing practices, we are not a model of wise restraint. All products combined, we led the rest of Canada with 30% higher spending and hold the first place in half of the 33 therapeutic categories of drugs listed, whose prescriptions are mostly renewable and lead to consumption over long periods.

Let’s look at the therapeutic categories in which Quebec leads the other 9 provinces, as well as exceeding the Canadian average, expressed as a percentage.

For cholesterol-lowering drugs (statins), the surplus is 46%. Disturbing when we consider that independent scientists no longer believe in the hypothesis of cholesterol and have replaced it by the “sugar hypothesis.” Prescribing statins “for life” to live longer could represent a waste of funds and resources, especially for women, the elderly and the healthy.

As for antipsychotics, the excess is 60%. For two antiepileptics (pregabalin, gabapentin) often used outside epilepsy in imprecise or unlabelled indications, our surplus is 118%. In the case of psychostimulants in ADHD, the expenses are 106% higher. Regarding the thyroid hormone, the excess is 68%. We dedicate 36% more for androgens (testosterone).

It costs us 29% more than the rest of the country for anticoagulants, 51% for anti-platelet pills, 74% for anti-multiple sclerosis products, 61% for anti-migraine drugs, 22% for respiratory condition agents, and 59% for osteoporosis medicines. The excess is 52% for hormonal contraceptives, 115% for hormone replacement therapy, 89% for benign prostatic hypertrophy pills and 26% for glaucoma eye-drops.

Antidepressants without confirmed depression

An investigation into the indications of 100,000 antidepressant prescriptions by 160 Quebec family physicians was published by Wong and colleagues from McGill University in the Journal of the American Medical Association in 2016. Only 55% of prescriptions wrote depression as an indication while the remaining 45% were for diagnoses not always included in the Health Canada-approved product monograph or not rigorously demonstrated after the marketing authorization.

The antidepressant prescriptions that failed to mention depression as an indication referred instead to a range of other health problems such as migraine, hot flashes, adult ADHD, erectile dysfunction, GI problems, insomnia, urinary disorders, pain of all sorts, post-traumatic stress, fibromyalgia, anxiety, obsessive-compulsive disorder, panic attacks, social phobia and premenstrual tension. It is right to question the logic behind a good portion of these prescriptions.

Conclusion

The prescribed volume is the responsibility of doctors, and so is the choice of more or less expensive products; this apparent collective trivialization of prescribing should challenge us and, if the prescription profiles were analyzed for their quality and efficiency, results would probably not make the front page. Doctors considered “big prescribers” of new medications should know that for most of these products, the superiority is uncertain, the risks little-known and the costs increased.

Over-prescription is partly due to the sprawling promotion to doctors, which goes as far as being conveyed by clinical guidelines signed by academic colleagues. Not to mention the shortcomings in the teaching of pharmacotherapy and of its critical analysis. These educational deficiencies are encouraged by the financial support that Faculties of Medicine and Continuing Medical Education programs regularly accept from Big Pharma.

Reference

[1] Steve Morgan et al. University of British Columbia Centre for Health Services and Policy Research. The Canadian Rx Atlas, 3rd edition, December 2013.

About the Contributor

Pierre Biron is a Honorary Professor of Medical Pharmacology at the Université de Montréal.

This text is a revised and translated version of an article that was published online in French in the Montreal daily Le Devoir, August 13, 2018.

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