It starts by looking at prescribing practices
by Alan Cassels
More than a decade ago, UBC’s Therapeutics Initiative (TI) published a very alarming newsletter. It made virtually no waves at the time, but it struck me as a dire prediction of the state of prescribing in British Columbia.
The newsletter simply asked two questions about benzodiazepine use in BC. This class of drugs include products like Ativan and Valium – or generic drugs that end in ‘pam’ – and zopiclone and are typically prescribed for anxiety and insomnia. The TI asked how many people in BC were using benzos and of those, how many were using them contrary to recommendations?
As prescription drugs go, benzos are widely, widely used even though they are recommended only for “short-term” use, typically less than 14 days. The benzos are not supposed to be taken over the long term because they are considered highly “habit forming,” the euphemistic way of saying they can be addictive. Once you take them for too long, stopping can be hell and those who try to quit abruptly will face withdrawal symptoms so bad they’ll just go back on the drug.
Over time, benzodiazepines lose their effectiveness, yet there is good evidence that when a patient becomes tolerant, the doctor may just increase the dose. Long-term use of the drugs can cause learning, memory and attention problems and their use is linked to falls, injuries, hip fractures and other types of accidents. The other important thing is that the benzos are frequently found on the street and up to 80% of street drug users are also taking benzos.
The TI’s analysis found that nearly 10% of the BC population – about 400,000 people at the time – used benzos (based on 2002 data) and of those, 170,000 people received amounts “incompatible with short-term or intermittent use.” In other words, almost 5% of the BC population were essentially at risk of being physically dependent on a drug they got from a prescription pad.
The current opioid crisis seems a modern version of the same phenomenon replaying itself, but this time the stakes are much, much higher. Even though we have some of the best monitoring systems in the country – e.g. BC PharmaNet, a computerized, province-wide drug data system – it doesn’t stop dangerously poor prescribing and poor monitoring by those whose job it is to protect patients: the BC College of Physicians and Surgeons.
Searching for insight into BC’s current opioid crisis, I came across a 2015 report titled “Together We Can Do This,” written by a panel of 73 experts in addiction medicine and pharmaceutical policy in BC. It helpfully maps out why BC broke all records in overdose deaths last year (914) and why, unless there is drastic action to improve prescribing, people in this province will continue to die from overdoses in massive rates. These experts lay out a series of strategies to address BC’s opioid addiction, an urgent cause given we’ve got among the highest overdose-related death rates in the world.
The report noted BC “dispenses more than double the amount of opioids compared to Quebec, the lowest opioid dispensing province. Additionally, from 2005 to 2011, the rate of dispensing strong opioids in BC increased by almost 50% overall, including a 135% increase in oxycodone dispensation.”
Now, with thousands of addicts in BC and daily reports of new deaths, there is a lot of pre-election interest on the part of the reigning BC Liberals, as money is doled out for safe injection sites, naloxone kits – the drug to revive a person who is overdosing – and increasing the training of emergency personnel. BC’s provincial health officer is talking about “clean heroin” and giving addicts provincially subsidized opioids, yet all this energy trying to clean up the damage misses the point that it was mostly created in the first place by poor prescribing and poor drug policies.
That’s the view of this expert panel, which concluded, “Despite the scale of the present public health problem, strategies to meaningfully address unsafe prescribing have not been implemented.” They add that many people who are addicted to heroin or other intravenous drugs started out with pharmaceutical opioids and “ultimately, prescribers are largely responsible for the burgeoning illicit market in pharmaceutical opioids that has developed on the streets of BC.” And here’s the kicker: “The entry of organized crime groups into the manufacturing of counterfeit pharmaceutical opioids, which often contain fentanyl, to fuel the street market for illicit or diverted opioids is arguably a direct result of long-standing, unsafe physician prescribing practices.”
Added all together, the crisis is a political and medical boondoggle. Like the dangerous abundance of benzodiazepine use in BC the TI documented a decade ago, we are seeing the same sort of lax approach to prescribing around the opioids. The headlines may focus on the illicit fentanyl-spiked drugs killing citizens at astonishing rates, but the real story is in the high rate of opioid abuse and addiction happening in the wider BC population. In the wider pool of opioid addicts are our friends and neighbours who have thousands of prescription pills, including Dilaudid, Oxycontin, morphine, T-3s and many other opioid pills, sitting in their medicine cabinets, leaving them and other family members who might want to experiment open to abuse.
In my small circle of friends, I know of at least two men who had hip surgery last year and both were discharged with scripts of 100 pills of Oxycontin, enough to turn both of those men into addicts. I know teenagers who were given Oxycontin following wisdom teeth extraction. And another friend, a very successful professional, came within inches of being addicted to the painkillers he was prescribed for a lower back problem.
What can we do if those prescribing the opioids simply don’t know the potential harm they could be causing? It has been well documented that our physicians’ dependence on weapons-grade opioids has been shaped by the drug industry. In the mid-1990s, Purdue Pharma, the makers of Oxycontin, spent millions underwriting Canada’s pain guidelines, paying “key opinion leaders” in the physician community to downplay the dangers of opioids and infiltrating medical school textbooks and medical schools, teaching our young doctors about managing pain. Opioids are very effective for pain, but for many people, there are many cheaper, safer, simpler and far less addictive medicines that can effectively treat pain instead of the expensive patented opioids pushed by their makers.
To my mind, the biggest scandal is that physicians continue to allow themselves to listen to pharmaceutical industry messages and to be educated by the drug salesmen and tainted experts. Many doctors won’t be schmoozed by drug reps, but others don’t see a problem. Hence, this is not the last prescribing disaster we will have to deal with.
I wish I could say the BC Liberals are doing all the right things, carefully monitoring prescribing and using their considerable clout through PharmaCare to stop this carnage. But they’re not. Beholden to pharma’s donations, they act as if powerless to stop the flow of prescribed opioids. We used to have programs in place that monitored prescribing, but there has been no political will to restart them. BC PharmaCare no longer takes advice from the Therapeutics Initiative and we’ve seen the slow death of drug safety evaluations in BC since the 2012 Ministry of Health firing scandal.
The BC College of Physicians and Surgeons will pretend to be tough with new guidelines and try to crack the whip on flagrantly bad opioid prescribing, but it may just drive even more people to the street to find the pain relievers they’ve become addicted to.
We’ve got many reasons to vote in a new government in May. Our spectacular rate of overdose deaths continues to climb. It is a national shame that deserves local blame. Christy Clark’s government’s addiction to donor dollars continues to make us a laughingstock of the world and the only ones not laughing are the dead, the dying and the addicted.
Alan Cassels is an author and drug policy researcher in Victoria.