Category: Health / Medical
Last Friday, the Ontario Ministry of Health announced plans to introduce legislation later this month that will allow the province to expand its drug database to track prescription drugs. The narcotics database will identify prescription ‘hot spots’ and alert officials when a patient attempts to fill prescriptions from multiple doctors at multiple pharmacies. Prescriptions under both public and private drug plans will be monitored. [Currently, the tracking system only tracks drugs prescribed under a provincial program that funds meds for seniors, welfare recipients and the disabled.] Provincial Health Minister Deb Matthews indicates that the plan will also work with regulatory groups like the College of Physicians and Surgeons of Ontario to create ‘better pain management strategies for its members’. The proposed narcotics strategy has received resounding support from both the Centre for Addiction and Mental Health (CAMH) and the Ontario Pharmacists’ Association.
Earlier this year, I blogged about the issue of ‘doctor shopping’, defined as the practice of visiting numerous doctors, dentists, or pharmacies to fraudulently obtain prescriptions for non-medicinal use. Of particular concern are narcotics and other controlled substances, including painkilling opioids (including morphine, codeine-containing Tylenol 2s, 3s and 4s, Percocet, Oxycontin, and Fentanyl), stimulants (amphetamines such as Ritalin) and sedatives (such as Valium, Xanax, and Ativan). Some stark statistics:
• In the past decade, prescriptions for oxycodone-containing drugs jumped 900% in Ontario. Last year, under the OHIP drug plan, the province spent over $150 million for narcotics, half of which was for Oxycontin.
• 18% of students (Grades 7 – 12) report using prescription opioids non-medicinally in the past year. The overwhelming source for the students’ opioids was not schools, or the street, but their own homes.
• Ontarians, per capita, use three times more prescribed narcotics than patients in other provinces.
• Last year, the Canadian Medical Association Journal reported that in Ontario, accidental deaths due to opioid use exceeded deaths from HIV.
As an aside, I am curious: In estate proceedings where testamentary capacity is in dispute, will the contents of the narcotics database be accessible pursuant to court-ordered production of “all relevant medical records”?
Jennifer Hartman, Guest Blogger
My friend owns a Chrysler dealership, and at the bottom of each of her ads, she includes a note in tiny font suggesting “Wise customers always read the fine print”. Those pondering organ donation in Ontario would be well-advised to follow this same adage. A number of significant changes have been made to the organ donation system in the Province:
• In addition to signing your Gift of Life Donor Card and informing your immediate family members of your choice to donate any/specific organs/tissue, you need to register your consent to donate. If you just carry the paper donor card, your wishes are only known to the extent that you have informed your family and friends. Once you register your consent to donate, your information is stored in a Ministry of Health and Long-Term Care database.
• To register consent, you can either: i) visit an OHIP office when you renew your health card; or ii) download a Gift Of Life Consent Form, fill it out and mail it to the address specified on the form. Online registration may be available at some point in the future.
• As of December 2008, you are no longer able to register a decision of “No” (i.e. No, I do not wish to donate organs/tissue). Only “Yes” decisions are now stored in the OHIP database. It is important to note that as of July 1, 2009, if you had previously registered a decision of “No”, this decision will “no longer be used or disclosed by the Ontario Government to Trillium Gift of Life Network”. Interesting catch-22: Should you choose to not register your consent, are you, by default, regarded as a “No”? The answer, is NO. If you do not register your consent, the TGLN will approach your family to discuss organ donation and your family may consent on your behalf if you are unable to do so.
• Your consent can be withdrawn at any time (again, by visiting an OHIP office, or in writing).
Spain, Italy and Austria all practice ‘presumed consent’ in which organs and tissue are considered property of the state unless one actively opts out. In 2007, the Health Law Section of the Ontario Bar Association, commented that an opt-out regime would be too radical a shift from the existing opt-in regime to garner public support. To wit, in a poll published late last week by Canadian Blood Services, 45% of Canadians were strongly opposed to a ‘presumed consent’ system of organ donation.
There are currently more than 4,000 Canadians waiting for organ donations, and each year, more than 200 die awaiting transplant.
Jennifer Hartman, guest blogger
My daughter turned 6 years old on Thursday, and on Friday, a pediatric ophthalmologist informed us that she is legally blind in one eye, and likely has been since birth. She can see light and motion with that eye, but little else. Parental shock would be an understatement. I am sharing our story so that others don’t fall through the cracks like we did.
With a background in health care, I made two assumptions, in error, along the way:
i. Surely I would be savvy enough to recognize signs of vision impairment in my daughter; and
ii. The sight screening performed at our GP’s office would act as an early warning system for any problems with her eyesight.
I was wrong on both counts.
At no time was there any indication that my daughter was having difficulty seeing. In fact, she excelled at school, both in terms of her reading and her writing. Further, as recently as a few weeks ago, she passed her sight screenings (with flying colours, no less), because she was asked to cover her own eye, and obviously cheated by peeking through the tiny gaps at the base of the fingers where they meet the palm. Sneaky little so-and-so.
A ‘sight test at a fixed distance’ comprised of covering one eye at a time and identifying letters/shapes on an eye chart is important, but it is not a substitute for a formal, comprehensive vision examination by an eyecare professional. Formal eye exams, once every 12 months, are not only recommended for school-aged children, but contrary to popular belief, they are covered by O.H.I.P. The Ontario Association of Optometrists is rolling out the Eye See…Eye Learn program in Halton, Hamilton-Wentworth, Windsor-Essex, Thunder Bay and Dufferin-Peel in September 2010. This program will educate parents of children entering JK about the importance of eye health, encourage them to take their children for comprehensive eye exams, and will even provide free eyeglasses if they are required.
My daughter wears a patch over her ‘strong’ eye for 3 hours a day in order to force her brain to establish connections with her ‘weak’ eye. We try to lighten up the process by letting her choose which patch pattern to wear; today she chose the patch with the lipsticks and high-heeled shoes on it. Some days she jokes that she looks like a pirate princess. That’s my girl. We are hopeful that we will see some improvement over the coming months, although we recognize that an earlier intervention may have been beneficial to her long term prognosis.
To find an optometrist near you, visit The Ontario Association of Optometrists website here.
Jennifer Hartman, Guest Blogger
‘Doctor shopping’ is the practice of visiting numerous doctors, dentists, pharmacies and/or emergency rooms to fraudulently obtain prescriptions for non-medicinal use. Increasingly making headlines, doctor shopping is considered to be the most common means by which people addicted to prescription drugs get their hands on their drugs. It is often assumed that someone doctor shops for the purpose of feeding their own personal addiction, however, there is a subset of doctor shopping activity for the intent of street sale. Depending on the drug, street value can range from $0.25 to $75.00, per pill.
Is it illegal? Under the federal Narcotic Control Regulations (made under the Controlled Drugs and Substances Act, 1996), “a person who has received a prescription for a narcotic shall not seek or receive another prescription or narcotic from a different practitioner without disclosing to that practitioner particulars of every prescription or narcotic that he or she has obtained within the previous 30 days”. To wit, in 2006, a Toronto woman was charged with filling prescriptions for almost 14,000 pills at nine pharmacies across the province.
How is it monitored? Nine of ten provinces have some form of system in place to track prescription-related information such as double doctoring. As an example, in 2008, Health Canada ordered pharmacies in Atlantic Canada to track narcotic prescriptions by family physicians after rates of narcotics abuse were found to be highest in that region. However, since there is no national surveillance system in place, the monitoring of doctor shopping and fraudulent prescription drug acquisition in Canada is a patchwork approach, at best.
How big is the problem? In 2002, Canada reported the fourth highest per-capita use of prescription narcotics in the world. The Centre for Addiction & Mental Health, in a study published that same year, indicated that 11% of admissions to substance abuse treatment programs in Ontario were for prescription drug abuse. A 2007 study released by the Canadian Centre on Substance Abuse (CCSA) cited evidence that “Canadians are among the heaviest consumers of psychotropic medication in the world”. And according to a 2008 study published in the journal Contemporary Drug Problems, North America has the world’s highest consumption of medical prescription opioids (consumption levels have, in fact, doubled in the past decade). Earlier this year, Narconon Alcohol and Drug Rehab Center reported that nearly half the calls they receive are with regards to prescription medications (primarily Oxycodone, Percocet and morphine).
How does prescription drug abuse relate to mental capacity? The most coveted drugs targeted by doctor shoppers are the opioids (including morphine, codeine-containing Tylenol 2s, 3s and 4s, Percocet/Percodan, OxyContin and other pain-relieving agents) and the benzodiazepines (including Valium, Serax, Xanax, Ativan and Halcion and other agents used for sedation, relief of anxiety or as muscle relaxants). These drugs are known to have detrimental effects on perception, attention, alertness, memory, orientation, attention and decision-making.
Jennifer Hartman, guest blogger
My colleagues and I recently attended the 10th Annual Fundraiser for Fanconi Canada, an inspiring event that raises money for Fanconi Anemia (FA), an inherited condition that leaves bone marrow unable to make new blood cells. 70 per cent of FA patients need a stem cell or bone marrow transplant. It occurs equally in males and females and is found in all ethnic groups. A truly non-discriminatory disorder.
FA is usually diagnosed in childhood, with the median age of diagnosis being 7 years old. Many affected do not live into adulthood. However, research is steadily improving the life expectancy of FA patients.
At the event I attended, the keynote speaker was a bright, articulate young woman in her early 20’s who had just graduated from University. She spoke eloquently and poignantly about what it means to have FA and how it pervades everything about one’s life. Like most young grads, she is applying for jobs, something she never expected she would be able to do. She is now coming to the realization that she must plan for her life and is moving forward with appreciation and optimism for the ordinary things many of us take for granted.
Estates practitioners know that it is important to plan for death; it is an inevitability that we will all face. But what the young woman with FA made so abundantly clear is that we must not forget to plan for life along the way as well.
If you would like to consider a donation or even plan for a charitable gift for Fanconi Anemia research in your own Will, see the Fanconi Canada Website.
Sharon Davis – Click here to learn more about Sharon Davis.
A conversation about driving with dementia exploded in the press in recent weeks. Everyone is weighing in on this debate, with potential stakes running obviously high. Certainly the decision to take away a patient’s licence could never be undertaken lightly, so how can a physician accurately determine driving risks associated with dementia?
A patient’s score on the Mini-Mental Status Examination (MMSE) score, when considered on its own, is a surprisingly poor predictor of a driver’s ability to drive safely. In fact, studies have shown that as many as 76% of patients with mild dementia are still able to pass an on-road driving test. Last month, in a strong effort to refine the entire process of assessing driving risk associated with dementia, the American Academy of Neurology issued updated guidelines for physicians. These updated practice parameters take into account the following characteristics that have proven useful for identifying patients at increased risk for unsafe driving:
• Clinical Dementia Rating Scale (CDR);
• A caregiver’s rating of a patient’s driving ability as ‘marginal’ or ‘unsafe’;
• The patient’s driving history, including accidents and citations;
• Self-reported ‘situational avoidance’ [Studies have shown that self-restricted driving, perhaps by avoidance of highway driving or night driving, or driving in inclement weather, or simply reduced overall mileage, is an accurate indicator of a driver at increased risk];
• An MMSE score of 24 or less; and
• Aggressive or impulsive personality characteristics.
This multi-faceted risk assessment brings the Americans more in line with the current Canadian approach, as outlined in the Canadian Medical Association’s document: Determining Medical Fitness to Operate Motor Vehicles CMA Driver’s Guide which takes this stance: "The driving ability of people with mild dementia should be tested on an individual basis. Studies have shown that a significant percentage of those in the early stages of dementia are able to operate a motor vehicle safely."
Jennifer Hartman, guest blogger
One of my first blogs (now colloquially referred to as the ‘thumb blog of 2008’) delved into the subject of cyberchondria, which was defined in the Globe and Mail as ‘hypochondria on metaphorical steroids, its effects amplified by the staggering number of disastrous outcomes the Web can provide’. Well if ever there was a black hole from which the cyberchondriac could never hope to escape, it would be found in the Apps catalogue on your iPhone and would go by the collective name “Medical Apps”.
I’m no dummy. I can see the value in Heartwise Blood Pressure Tracker; you type in your blood pressure and heart rate and can then monitor trends over time. Handy app if I have a blood pressure problem. I get that.
Speaking of blood pressure, though, I’ll venture a guess that the Infections App would really do a number on a hypochondriac; everything you could ever want to know about anthrax, dengue fever, monkeypox and more, all at your fingertips.
And the temptation to self-diagnose must be irresistible if you’ve downloaded X-Rays, a nifty little App (free, no less), for identifying any sort of abnormality as a result of disease, injury, or simply poor genetic misfortune.
What I do find most unnerving are the Apps that are obviously targeting physicians. Instant ECG: An Electrocardiogram Rhythms Interpretation Guide is one example. Not sure how confidence-inspired I would be to watch my cardiologist whip out his iPhone to make sure I wasn’t in atrial fibrillation. Ditto for “ICU Pearls”, which the developer describes as ‘pearls of wisdom’ for the ICU doctor. Call me ungrateful, but if I’m in the ICU, I’m probably not there for a life lesson.
I scored an iTouch for Mother’s Day this year. I’m already getting wicked finger cramps exploring the full scope of what it can do. But don’t worry about me, there’s an App for that.
Jennifer Hartman, guest blogger
In the course of reviewing medical records in advance of estate litigation, one will encounter a wide variety of cognitive screening tools used to identify cognitive impairment. A handful of these tools are described here:
• Confusion Assessment Method (CAM): an ICU assessment tool used to detect the presence or absence of delirium. A CAM assessment is usually carried out once every 8-12 hours (once per nursing shift). Results are presented as either ‘CAM-positive’, or ‘CAM-negative’, indicating the presence or absence of delirium, respectively.
• Mini-Mental Status Examination (MMSE): a quantitative measure of cognitive status in adults. Despite its well-documented limitations, the MMSE is the most widely used standardized cognitive screening test in both clinical practice and research. Scores (out of a maximum 30 points) are paired with an associated level of impairment, i.e. no impairment, mild impairment, moderate impairment or severe impairment.
• The Montreal Cognitive Assessment (MoCA): a rapid cognitive screening instrument used to detect mild cognitive impairment. This user-friendly tool assesses attention and concentration, executive functions (these are the high-level abilities that control more basic abilities and behaviours), memory, language, conceptual thinking, visuoconstructional skills, calculation and orientation. Studies have shown the MoCA to be far more sensitive than the Mini-Mental Status Examination (MMSE) in its ability to detect mild cognitive impairment.
There are dozens of other cognitive screens in use including the Mini-Cog, the Rowland Universal Dementia Assessment Scale (RUDAS), the Clinical Dementia Rating (CDR), the Memory Impairment Screen (MIS), and the recently published Self-Administered Gerocognitive Examination (SAGE). In the context of a dispute regarding testamentary capacity, cognitive screening results are valuable for the estate practitioner, in that they provide tangible, measurable, time-sensitive information regarding the testator’s cognitive functioning, and serve as a tool for assessing the progression of the impairment.
Jennifer Hartman, guest blogger
A fifth edition of the Diagnostic and Statistic Manual of Mental Disorders (known as the "DSM-IV") is imminent, according to the chair of the task force responsible for the fourth edition, Dr. Allen Frances, quoted in this National Post article. The DSM-IV is considered the most authoritative manual for defining and classifying mental illnesses.
The relevance to capacity litigation is that the language doctors use to talk about patients and record their observations may change, perhaps significantly. According to Dr. Frances, revisions to the definitions of attention-deficit hyperactivity disorder, autism and childhood bipolar disorder (i.e., manic depression) resulted in an unintended 40-fold increase in rates of diagnosed bipolar disorder. A patient’s diagnosis is a major variable in his or her treatment. There was a dramatic increase in prescriptions of anti-depressants over this period.
Revised definitions would not necessitate corresponding changes in legal capacity, of course. The tests for the various levels capacity are functional in nature; they evaluate an individual’s observed ability to make decisions and do things. Good capacity assessments tell a story, and the elements of the story must support the conclusions reached. If not, the assessment will be rejected. Re Koch is instructive on this point. It is hard to read the judgment and imagine that including medical terms would have made any difference at all.
On the other hand, changes to the DSM-IV may be very relevant for expert opinions on capacity given after an individual’s death, where the opinion relies heavily on medical reports and observations of treating physicians to assess an individual’s capacity at a specific time during that individual’s life.
Have a great day,
Christopher M.B. Graham – Click here to learn more about Chris Graham.
The next Medical/Health series of blogs is scheduled to hit the platform on Monday May 3rd, 2010. The series will run every Monday thereafter in the month of May (with the exception of Victoria Day), for a total of four blogs.
To keep things fresh, relevant and engaging, we are inviting suggestions for topics from you. Is there a specific medical condition you’d like to see an overview for? We have blogged on strokes, brain injury, alcohol abuse, pharmaceutical abuse, dementia, the Ontario Mental Health Act, and palliative care, just to name a few. Perhaps you would like to see one of these capacity-related topics explored in more detail?
Please forward your suggestions to email@example.com .