A year after provincial governments clamped down on the most notorious name in prescription-drug abuse, other, more powerful, less regulated opioids are filling the void – with sometimes fatal results.
OxyContin’s off the market, its tamper-resistant replacement tougher to get. But Canadians are popping more pills than ever: In 2010, for the first time, Canada edged past the United States to become the highest opioid-consuming country, per capita, in the world.
And more Canadians are dying from it: In 2011, twice as many Ontarians were killed by opioid overdoses as drivers killed in car accidents, according to coroner’s statistics given to Global News. That toll has more than tripled since 2002.
In the meantime, publicly funded addiction treatment programs are overflowing with people addicted to publicly funded drugs.
The Canadian Centre for Substance Abuse is poised to release a slew of recommendations on how to tackle Canada’s pill problem. They’ll likely suggest making these drugs harder to crush, snort and inject, and putting an extra layer of scrutiny in place when physicians prescribe high doses of high-potency opioids.
Whether policy-makers follow through is another matter altogether.
“What we’re getting is a document,” said Ada Giudice-Tompson. “I want to see some action. I want to see something unfold.”
Giudice-Tompson has been waiting for action on prescription-drug addiction since her son Michael died in 2004, killed by a drug his doctor gave him. So far, she’s been disappointed.
The past decade has given her a crash course in pharmacology and the politics of health-care policy. She sat in a Brockville, Ont. courthouse to watch an inquest into a pair of opioid overdose deaths and has spent the past year with doctors, police officers, bureaucrats and pharmacists trying to hammer out a solution. And she’s had enough of national strategies with no teeth behind them.
“The government has to do more.”
It’s a thorny issue, tackling misuse of medications genuinely needed by people in pain. But some of the advice in Wednesday’s report should be familiar territory: Apply the same constraints placed on OxyContin – tamper-resistance and a second set of eyes approving prescriptions – to other powerful, long-acting opioids that have become more commonly prescribed in almost every province.
Neither Ontario Health Minister Deb Matthews nor Assistant Deputy Minister Diane McArthur was available for an interview for this article. A spokeswoman said in an e-mail that the ministry “will continue to monitor the utilization of hydromorphone contin and other opioids to determine if changes to reimbursement for these products should be made, including whether it may be more appropriate to consider other access approaches such as the Exceptional Access Program.”
A one-drug crackdown
Last March, nine months before its patent was to expire, Purdue Canada replaced OxyContin with OxyNEO, an alternative billed as “tamper-resistant” – tough to crush and therefore harder to snort or inject.
Several provinces took the opportunity to tighten their rules for one of the names most commonly associated with prescription opioid abuse. Ontario, British Columbia, Saskatchewan, Manitoba and Prince Edward Island only cover new OxyNEO prescriptions in exceptional circumstances: You can get it if you need it, but that extra step is supposed to make doctors think twice before prescribing.
It appears to have worked. Ontario’s OxyNEO prescriptions are about 60 per cent what OxyContin prescriptions were a year ago; in Newfoundland, they’re 22 per cent; in B.C., 67.
But prescription statistics obtained by Global News indicate the restrictions provinces have put in place for OxyNEO do little good if they don’t apply to other drugs: When OxyNEO replaced OxyContin it didn’t come anywhere near its predecessor’s prescription rates. But other drugs are rapidly making up the difference: Fentanyl, most commonly prescribed in patches, is among them; so is Hydromorph Contin, a long-acting opioid made by OxyContin-maker Purdue Pharmaceuticals.
Hydromorph Contin and Fentanyl have neither the name recognition nor the negative association that OxyContin garnered. “OxyContin’s a hot word. Some people don’t go in asking for it any more,” said David North, head of Tri-county Addiction Services in Brockville, Ontario. “They go ahead and find new drugs.”
Milligram for milligram, the active ingredient in Hydromorph Contin is about two and a half times more powerful than the active ingredient in OxyContin. Fentanyl patches are designed to provide up to 72 hours’ worth of painkiller; smoking, chewing or injecting to get that high all at once makes overdose much more likely.
The difference in strengths can cause confusion even for medical professionals: Last year, a northwestern Ontario man died of an apparent opioid overdose after his doctor gave him an incorrect prescription when switching him off of OxyContin.
Fentanyl and hydromorphone, the active ingredient in Hydromorph Contin, are among the fastest-growing causes of Ontario’s opioid overdose deaths.
“There’s a tendency to shift to other drugs of abuse when you restrict access to one,” said Bert Lauwers, Ontario’s Deputy Chief Coroner. “When the microscope was focused on oxycodone and the education occurred with oxycodone, physicians will look to other drugs.”
Giving prescribers ‘some hoops to jump through’
At the Halifax pain clinic where Mary Lynch works, OxyNEO has become harder to get. So “sometimes we have had to make a substitution,” she said. “And other options would include hydromorphone and fentanyl.”
The restrictions haven’t meant she prescribes fewer pills – just different ones.
But it isn’t a surfeit of drugs that concerns her: Lynch worries the hype around these painkillers will scare doctors out of treating pain altogether.
“More and more, we’re having family physicians saying, ‘Uh-uh. I’m not going to prescribe this. It’s only going to be trouble.’” As far as Lynch is concerned, “our main problem is under-treatment and inadequate access to treatment.”
David Juurlink doesn’t see things quite the same way.
“The unfettered access to whatever dose or duration of opioid a physician or patient desires is part of the reason we got here,” he says.
Juurlink, a physician and addiction researcher at Toronto’s Sunnybrook Health Sciences Centre, argues doctors should have “some hoops to jump through” before they prescribe powerful, long-acting painkillers.
Easier said than done: It could be costly, and a logistical nightmare, to staff a program checking every single long-acting opioid prescription. But if it works as designed it would save money as well as lives: Fewer drugs to pay for and, in theory, fewer addicts to treat.
The number of people in Ontario methadone programs more than quadrupled in a decade. But the price tag on a program (about $6,000 per person, per year) is cheap compared to the estimated $44,000 it costs to have an addict go untreated.
Andrew Losier had a much easier time finding someone to sell him pills than a treatment program to wean him off them.
The Kemptville native first tried OxyContin on a roofing job in the summer before Grade 12, but it was Hydromorph Contin, bought in 30-milligram tablets from a cancer patient, that became his drug of choice. “He was getting a lot – the patches, the pills, the injection stuff,” Losier said. By the time the man passed away, Losier says, “I was left with a friggin massive habit.”
After a stint paying for heroin with meat stolen from grocery stores, he moved back in with his mom and decided it was time to get help. So he called up a tapering program he knew of in Elliot Lake.
“They said, ‘Listen, there are a lot of people who want to kick dope … so there’s a waiting list. They’d call once a month to make sure I was still around and still interested.”
‘What bugs me … is how slowly everybody moves’
Irfan Dhalla, a physician at St. Michael’s Hospital in Toronto, has watched the issue of prescription-drug abuse gain traction in public discourse over the past few years. But “we’ve not actually seen, to date, a reduction in the number of overdose deaths.
“What bugs me a lot about this whole issue is how slowly everybody moves,” he said. “Here’s an issue that could be saving hundreds of people’s lives every year.”
Part of the hold up, Dhalla and Juurlink argue, is that addiction doesn’t carry the perceived urgency of other public health problems.
“If a group of people was sickened from eating tainted hamburger and 13 people were in hospital with E.coli poisoning, it would be a major news story: The government would be all over it,” Juurlink said.
“But if 550 people are going to die this year in Ontario, and more than 1,000 in Canada … I don’t know why it’s not front and centre.”
Tomorrow: The view from the world’s potent-opioid capital