DRUG BUST by Alan Cassels
• Calvin, the central character of my column this month, is a nice, hard-working guy who could be anyone’s relative. But he’s not a real person; he’s a composite I created out of several people whose stories I have followed over the years. In this scenario, he’s a 32-year-old carpenter who had a minor accident a few years ago where he fell and hurt his back. He was prescribed tramadol and later oxycodone – a widely prescribed opioid narcotic – to help control the pain. Over the next few weeks, he got a bit of physiotherapy to strengthen his back and his pain slowly lessened, but not his use of the drug. After three weeks, he tried to stop taking the oxycodone, but he experienced such incredible aching, sweating and chills that he went right back on it. Calvin may not have needed the drug anymore, but he couldn’t stop because of the withdrawal symptoms every time he tried to quit.
Here’s where the story gets interesting. When his supply started running low, he went back to his doctor and after two refills, the doc told him he couldn’t prescribe them anymore. Desperate, Calvin found that, on the street, a single pill of “Hillbilly Heroin” – the street name for OxyContin – costs $10. So that’s where he got his supply from until one day, one of the dealers suggested he try heroin, advising him it was cheaper and easier to find. Within three months of his accident, Calvin was now an unemployed heroin addict, barely holding it together and wondering where he was going to get his next fix.
Today, when people use the term “abuse” in relation to prescription drugs, they are almost always referring to opioids – powerful, pain-relieving drugs like morphine, hydromorphone, oxycodone, tramadol, fentanyl and others. The abuser is often characterized as a crazed druggie whose unravelled life is due to his own character flaws. Yet when one considers that many people like Calvin became that way through serious flaws in the system, we have to ask, “Are we doing enough to avoid these preventable tragedies that destroy peoples’ lives?”
From 2010 to 2014, opioid prescribing in Canada jumped 25 percent to more than 22 million scripts going out the door every year, according to the pharmaceutical data firm IMS. Data from the Pain and Policy Studies Group at the University of Wisconsin-Madison show that Canada has the second highest opioid consumption in the world after the US. We swallow almost 10 times as many opioids per capita as people in the UK, five times as many as France and four times as many as New Zealand. According to data from Ontario’s coroner office, prescription opioid-related deaths in Ontario doubled between 1991 and 2004 and more than tripled between 2004 and 2012. In 2012, there were 536 opioid-related deaths in Ontario alone; extrapolated across the country, that would give us about 1,400 opioid-related deaths in Canada per year. The US, by contrast, has about 19,000 opioid related deaths per year. Other countries have people in pain who need pain relief; why are they not seeing the gross numbers of overdoses and deaths related to opioids as we are in North America?
Some people maintain the solution is to crack down on opioid prescribing because most of the “abusers” are getting the drug from a prescription pad. But it is highly problematic to make access to these drugs too strict; you would end up denying too many legitimate patients who need help for their severe pain. At the same time, making the drugs too easy to get means people can more easily become addicts, with more of the drug ending up on the street, adding to society’s overall toll of addiction, overdoses and deaths.
Clearly, one of the best ways to reduce the deaths from opioid abuse and overdose is to encourage doctors to consider other, possibly safer medications to start with. Most would agree that better education – both for physicians and patients – on the full range of possible pain treatments may steer more people towards drugs that are less addictive and less dangerous. Alternative ways to treat pain, such as physiotherapy, chiropractics and even cognitive behavioural therapy, can be very helpful for many people, but they are more difficult to access and not as widely covered. Pain clinics that specialize in treating patients with a range of measures are helpful, but waiting for a pain clinic might take months or years.
Things have radically changed in the last two decades around the use of these drugs. It used to be that opioids were only prescribed for people with the severe, acute pain that comes with surgery or cancer. There are very effective treatments for non-cancer pain that aren’t addictive like the opiates, but when OxyContin began to be widely promoted in the mid 1990s, physicians were told the drugs were less addictive and safer than they actually were.
Prior to about 1996, the year OxyContin was approved in Canada, overall opioid prescribing was a fraction of what it is today. Purdue Pharma, the drug company marketing OxyContin, crafted a narrative stating its new drug was a safe, long-acting drug designed to treat chronic pain. To enhance that message, the manufacturer funded promotional materials for medical students, including textbooks on prescribing for pain. By downplaying the addiction potential of opiates like OxyContin, not only were patients getting addicted, but doctors were exposed to biased and dangerous information. Patients suffered and died because of that faulty advice.
So back to Calvin. We might ask if he could have been better served with a non-opiate drug for his pain. Did anyone ever tell him he might become dependent on the drug? If someone recognized that things were going off the rails for him, wasn’t there a safer option than turning to heroin?
Two Toronto-based drug policy experts, Dr. Joel Lexchin and Jillian Clare Kohler, have studied the promotion of OxyContin in Canada and the US, which they think is behind the widespread use and abuse of that product. Writing in the International Journal of Risk & Safety in Medicine, they say that any drug with a “high potential for abuse” should be strictly overseen by regulatory authorities for the first two years it’s on the market. They also say “prescription event monitoring programs” should be set up for these drugs so that any adverse events experienced by the patients for at least six months after the drug is marketed can be collected and reported.
Dr. David Juurlink, a Toronto physician who is a stern advocate for rationality in the opioid wars, has followed the opiate issue intensely. He thinks things might be levelling off and slightly improving, but there is still a long way to go. He told me in an email that even when doctors agree about the dangers of opioids, many of them “have unreasonable views on the safety and effectiveness of these drugs and often look for excuses to blame what are clear drug-related problems on other things.”
At the end of the day, people like Calvin, when trying to stop or reduce their dose of an opioid, will develop early features of opioid withdrawal and that means they will continue to take the drug just to function.
I have a lot of sympathy for doctors on this issue and perhaps even more for patients like Calvin, whose life has fallen into a pain dumpster and he can’t get out. Since our doctors clearly want to help, but don’t have time to become detox experts, my non-expert opinion is that the Calvins of the world need better options and a better system to care for them. As an individual patient, what should you do? There are no easy answers except to say if you are in severe pain, you will want to go slow and go low on these drugs. You’ll need to work with your doctor to help minimize the harm and maximize the benefit for every single prescription you get.
This is not easy. We have a national tragedy on our hands, but we also have the means to fix it.
Alan Cassels is a drug policy researcher in Victoria. His most recent book, The Cochrane Collaboration: Medicine’s Best Kept Secret, has just been published. Follow him on twitter @AKECassels