Drug History Canada

Musings on the history of drugs in Canada.

Category: prescriptions

Fentanyl crisis and historical perspectives

Over the past month or so I’ve been mulling over the current opioid crisis and what it means, and of course what history can tell us about it.  It culminated in an op ed in the Globe and Mail entitled “Why is everyone talking about painkillers, but not about pain?” I felt that this article in its 700 word format was a decent introduction to the complexity of the current opioid crisis, but of course there is so much to say.

Having written op eds before, on cannabis legalization and liquor control, I don’t think I was prepared for the type of attention this article received.  I guess it was the timeliness and the national scope, but also the emergent nature of the crisis. I will in the next few days try to capture some of the response without betraying any confidences. Suffice it to say when dealing with pain and medical treatment, people have a lot of stories to tell, and they need to tell them.  As the recipient of these stories, I’ve been humbled and saddened but also enlightened. Moreover, it has reinforced my resolve that the current painkiller crisis has much deeper roots and needs more concerted efforts to address its origins.

Ask and you shall receive; seek and ye shall find.

So I’ve been a little lax on updates and am trying to catch up. this post is actually about something I found in Saskatchewan in autumn 2012.

But some background.

My research has involved a lot of digging through pharmacy records.  I’ve done some detailed data collection of records from pharmacies in Ontario, Alberta, and British Columbia, as well as less detailed stuff from Nova Scotia.

This often involves reading prescription ledgers, or going through prescriptions pasted into big scrapbooks.  Depending upon the province, pharmacy laws had different requirements for saving prescriptions.  for example, in BC, the pharmacy legislation of the 1890s deemed the prescription to be the property of the customer. Consequently, instead of having to go through prescriptions that were written by individual physicians, with a variety of terrible hand writing styles, we get lovely ledgers written in a consistent and usually highly legible script. Thank you BC legislature!

In Saskatchewan I was a little flummoxed because I couldn’t find much in the way of prescriptions, and I wanted to try to be as broadly-sweeping as I could.

In finding archival records, the challenge can usually involve getting inside the head of the person who catalogued the records when the records arrived at the archives or library special collections office.

To deal with this problem of finding records, we have to go old school.  We have to do something that seems counter instinctive in this digitally catalogued age. We have to speak to people.

During my research, I was chatting quite a bit with archivists at the Saskatchewan Archives Board site located at the University of Saskatchewan.  (The Board has two offices, one in Regina and one in Saskatoon).

Archivists are of course a historical researcher’s best friends.  Because, as I’ve said before, they have stuff and they want you to use it.  (Normally, that is. Some places don’t want you to use it, and that’s an entirely different issue).

The archivist suggested I look at records in the U Sask special collections.  The contents of this material was not catalogued in such a way that it would be easy to find.  But she was pretty sure there was some substantial pharmacy holdings there.

Boy was she right.

The material is catalogued under the name of W C MacAulay, who was Dean of the College of Pharmacy in Saskatchewan from 1946.  Looking as I was for pharmaceutical records from the 1800s and into early 1900s, I’d not considered the records of someone who was born in 1909 to be useful for me. But in his position, MacAulay seems to have collected a lot of stuff.  It included the following list, from Series VI (in a fonds that is stated to have five series, this can be additionally surprising).

In the interest of making this information available, and with the consent of the librarian in the U Sask special collections office, here is what MacAulay’s records have as far as prescription records in Saskatchewan:

W.C. MacAulay Fonds. –  MG 43. – [ca. 1884]‑1975 (inclusive); 1921‑1975 (predominant).

[textual records + photographs]. – 6.6 m.  – M4.1-3.

[other Fonds material removed from this listing]

VI. Pharmaceutical Archives. – 1890-1954. – 6 m.

This series contains records, prescriptions, prescription books, ledgers, poison books, log books, and prescription formulae of various early pharmacies and pharmacists reflecting their practises and activities as well as association registers.

BOX 15

1. F.T. Carman – Moosomin, NWT. – 1892-1895.
Prescription Books.
Vols 1-2 – #100-1500 – [ca. 1884-1885].
Vols. 3-6 – #1520-3577 – [ca. 1886-1887].
Vols. 7-10 #3578-6057 – May 28, 1888-[ca. 1890].

BOX 16

Vol. 11 – #8066-9392. – Jan-Oct 1892.
Vol. 12 – #9393-B862 – Oct 1892-June 1893.

Vol. 3 – #B863-B2277. – June 1893-Mar 1894.

BOX 17

Vol. 4 – #B2278-B3729. – Mar 1894-Jan 1895.
Vol. 5 – #B3737-B5204. – Jan-Dec 1895.

BOX 18

2. W. Pennington – Moosomin, NWT. – 1895-1946.
Prescription Books.
Vol. 1. – #B5206-B8079. – Dec 1895-Apr 1897
Vol. 2. – #B8080-19829. – Apr 1897-July 1898.

BOX 19

Vol. 3. – #19830-21541. – Jul 1898-June 1899.
Vol. 4. – #21542-23271. – June 1899-Sept 1900.

BOX 20
Vol. 5. – #23272-25986. – Sept 1900-Oct 1901.
Vol. 6. – #25987-27844. – Oct 1901-Oct 1902.

BOX 21

Vol. 7. – #27845-29589. – Oct 1902-June 1903.
Vol. 8. – #29590-31307. – June 1903-Apr 1904.

BOX 22

Vol. 9. – #34607-36174. – Sept 1905-July 1906.
Vol. 10. – #41321-43078. – Nov 1908-Aug 1909.

BOX 23

Vol. 11. – #23654-24197. – Oct 1935-Aug 1937.
Vol. 12. – #245727-266254. – Dec 1938-Mar 1940.
Vol. 13. – #266749-268227. – Oct 1941-Feb 1943.
Vol. 14. – #59001-59500. – July 1946-Aug 1946.

BOX 24

3. W.L. Carley – Moosomin, NWT. – 1902-1930.
Vol. 1. – #12100-19645. – Feb 1902-Nov 1903.

BOX 25

4. J.H. Abercrombie – Togo, Saskatchewan. – 1905-1930.
Vol. 1. – Feb 1905-Dec 1915.
Note – a miscellany of prescriptions appear on the last few pages of this volume.
Vol. 2. – Jan 1916-July 1919.

BOX 26

Vol. 3. – July 1919-June 1922.
[A.J. Leach, pharmacist?].
Vol. 4. – July 1919-Apr 1922.
[J.H. Tripp, pharmacist?].

BOX 27

Vol. 5. – Jan 1925-June 1930.
[A.J.  Leach, pharmacist?].

5.  A.J. Leach. – Togo, Saskatchewan. – 1921-1924.
Vol. 1. –  Mar 1921-Dec 1924.
Note – Includes some scripts from J.I. Wallace of Kamsack, Saskatchewan.

BOX 28

6. J.H. Tripp. – Togo, Saskatchewan. – 1922-1935.
Vol. 1. – Apr 1922-Dec 1925.
Note – includes some scripts from J.H. Abercrombie of Togo.
Vol. 2. – July 1926-Feb 1935.
Note – includes a miscellany of scripts from other pharmacies and pharmacists.

BOX 29

7. University of Saskatchewan Pharmacy. – Nov 1953-Sept 1954.
Files 1 and 2. – 4001- 4998.  – Nov 1953-Sept 1954.

BOX 30
8. Pharmacy Ledger and Log Book. – 1890-1893, 1907-1911, 1933-1934.
Vol. 1. – Ledger.
Daily accounts, Nov 1890-July 1893.  Individual client accounts complete with purchases, prescriptions and payments between 1890 and 1895.
Vol. 2. – Log Book.
#6292 – 9204. – Oct. 1907-Feb 1911.
#1000 – 1359. – Apr 1933 – June 1934.

Saskatchewan Library records information is the property of the University of Saskatchewan and reproduced with permission.

Remaining post (c) 2014 Dan Malleck

Whose control is it, anyway?

So those upstart pharmacists and nurse practitioners want to edge in on doctors’ business!

Recently, across the country, various health practitioners have been seeking to expand their scope of practice. This is the legally defined range of activities they are allowed do. In the health system, especially, it is a highly contentious issue. Because unlike other professionals, whose work is also restricted and protected by law, when health professionals do stuff, it affects people’s health.  And just ask any health ethicist. Unlike buying a car, or getting your house painted, or even renovating your bathroom, the transaction you have with your health professional affects you in a way that can affect your well being,  quality of life, and sense of self.

We can understand scopes of practice by looking at history.

The scopes of practice for health professionals have been developed over decades, if not centuries.  In Ontario, in the middle of the nineteenth century, doctors and pharmacists, argued over what activities should be their specific areas of authorities.  Generally physicians won these arguments, since the pharmacy laws which gave pharmacists legal right to compound and distributed a specifically listed set of substances, normally exempted physicians from those rules (docs often carried drugs with them and it was often, in a rural country as ours was, much more efficient for them to sell or give drugs during treatment then to require a patient to head to the local pharmacy).

Some physicians exploited this loophole.  Some opened their own pharmacies, finding these were much more lucrative than a medical practice. A pharmacy could sell other goods that it might not be so expedient for a physician to carry in his saddle bags, so if you could build a good solid mercantile business, you were in the money.

At the same time, some pharmacists also infringed on the physicians’ domain. A customer comes in and has a cough and is looking for  a remedy.  What do you do?  Send them to a doctor to get a ‘scrip for a cough medicine? Or compound some simple syrup, cherry flavour and opium and voila, cough medicine (this would probably be what the doc would prescribe anyway)?  Well, to the docs, this was a violation of the legal scope of practice. To the pharmacists, it was just serving their customer. The courts were divided, but most saw selling something to a patient to deal with a simple symptom was not the same as diagnosing and prescribing.

There were other issues of intersection, and I’m currently exploring them in more detail.  I’ll try to post more information and thoughts when I find more great examples.

The point, though, in respect to current debates about scope of practice, is complex.  

Scopes of practice were contested, debated, lobbied for, and not always established with 100% control.  When doctors in Ontario saw the legislation passed that gave them professional status and control over who would be allowed to practice medicine, they had to share this responsibility with homeopaths and practitioners of a few other types of alternative modalities.  Homeopathy was popular, especially among elites, and the idea of an absolute monopoly over any single occupation rubbed our laissez faire-ist ancestors the wrong way.

So these current debates are part of a process of evolution and change

But when it comes to drugs, there is another historical process at work: the construction of danger embedded in the prescription.

When pharmacy laws were passed they had two purposes. The first was to control access to “poisons” which were being used purposely or mistakenly to kill.

Suicides, murders, accidents. These were sometimes linked to drugs.

Strychnine, arsenic, opium. These were the poisons.

Taken in high enough doses, they’ll kill you. But they were also medicines.  

So the pharmacy law was designed to place control over highly dangerous drugs in the hands of professionals who knew how to use them. And since usually pharmacists were also compounding remedies (a doctor would send a recipe and the pharmacists would mix it) there was some skill in the actual process of assembling, measuring, etc. 

But what happens when something becomes controlled? Well, the idea that medicines should be controlled by professionals expands the scope of that control. By the end of the century, there were more arguments for more control over substances that, while not poisonous, might in some ways cause some damage to a patient.  The range of “controlled substances” expanded as the pharmacopoeia did. Why is an antibiotic a prescription drug?  It’s not likely going to kill you. But if you take it too often, it will become ineffective. How about oxycontin?  Well, it is an opiate, so it might kill you, but it will more likely addict you.  Both of these, of course, carry their own dangers, and some very significant ones, but they are not poison in the traditional sense. They are, however, controlled.

So when docs, nurses, pharmacists and others begin to talk about who should control the prescription and administration of certain drugs, pay attention to the way the idea of danger emerges.  What is dangerous?  How dangerous? How much risk is there in a different professional administering an antibiotic or a vaccine?  And is that danger so severe that the practice should be strictly controlled to one professional? And should one profession have that much authority?

It’s worth considering.  Because these ideas of danger, control, abuse, misuse, and professional authority are infused with complex meanings. The meanings are historically grounded, and evolve and even transmogrify. As these debates continue, ask what is really being discussed.

And then look to an historian to unpack it for you.

(c) 2014, Dan Malleck

Why do pharmacists control access to certain drugs?

I had a student who is diabetic come to speak to me today, and in the meandering way conversations I get into with students go (usually my fault), she ended up asking the rhetorical question “why do I have to get my insulin from a pharmacist?”

It is a good question.  As I noted in the last post, the issue of the “dangerous”ness of drugs drove the construction of control of access to some drugs.  But what about insulin?  It’s not addictive; it’s not really poisonous (at least no less so than non-drugs you could surreptitiously administer and kill someone, like antifreeze) and it’s an essential substance for some people to receive artificially.

To be honest, I’m not sure.  I told the student that she could do a directed reading with me and we could explore the idea. I love it when I have motivated students like that, and questions I can’t answer.

I do have some guesses, though.  They are really nothing more than suppositions based upon my thin knowledge of the process

  1. Insulin, when it was first isolated, was relatively difficult to get your hands on.  Controlling access through a pharmacist or doctor would allow its use to be judicious.
  2. Controlling access to insulin was easy to justify because diabetes itself had to be diagnosed.  Without such a diagnosis, you’d not know you had diabetes. So there was no real way to self-diagnose, and no need in the market to have it available for over the counter sale.
  3. By the time insulin had been isolated and seen to be an important medical tool, the idea of expanding medical jurisdiction over access to such technology was sort of a given. Maybe it was just natural that new important substances like insulin would be available only by prescription.
  4. It made it more expensive. Big pharma loves something that makes drugs more expensive (I doubt this was the case).
  5. It needs to be injected, which makes the hormone insulin need to be administered by docs.  See #2.
  6. None of the above
  7. Many of the above.

I really have no idea.  I will look into it though.  It’s a compelling thought, and will fill out the complexity of my narrative on the relationship between legislation that controls access to medicine, and the authority and social role of the medical industrial complex.

Interested in this question?  Have some ideas?  Post a response.  Share thoughts.  I have to come up with a reading list at some point, so you’d make my job a lot easier.

Your responses are copyright: you.

My post is (c) Dan Malleck. 2012.