Inside Canada’s Prescription Drug Problem
What the highs and lows of the opioid trade can teach us about regulating other substances.
Thamesville, Ont., population 928, is part of the municipality of Chatham-Kent, about an hour and 15 minutes from the Windsor-Detroit border. In its latest forecast, the Chatham-Kent Chamber of Commerce described the immediate prospects for the local economy as “not promising,” citing a shrinking population and the exodus of heavy industry. In Thamesville, the only business that seems to be prospering is the Westover Treatment Centre, an addiction-recovery facility. Its massive front lawn is green, the august grounds evoking a well-to-do rural university.
Chatham-Kent’s communities have, like much of Ontario, seen a steady rise in prescription opioid misuse over the past two decades. In 2007, almost 30 per cent of high school students in the Erie St. Clair Local Health Integration Network, an area that includes Chatham-Kent, admitted to having used prescription opioids for non-medical purposes at least once in the previous year, according to the Ontario Student Drug Use and Health Survey.
There are many potential reasons for Chatham-Kent’s high rate of opioid misuse, perhaps including the region’s recent economic downturn. Ron Elliott, the executive director of the Westover Treatment Centre and a pharmacist by training, notes that the spread of prescription opioid addiction is also due to a shift in prescription patterns. As a pharmacist in the 1990s, Elliott saw physicians start prescribing huge amounts of painkillers, such as OxyContin. “I was getting scripts at one pharmacy for 500, 600, even 700 Oxy pills,” he says. “And every time I challenged them, I was reassured that this is what’s always done.”
Elliott’s experiences were symptomatic of a larger trend. Between the years 2000 and 2002, and then again between 2010 and 2012, Canadians’ consumption of prescription opioids-opium-derived drugs like OxyContin and Percocet-more than tripled, according to data from the International Narcotics Control Board. That is a faster climb than in the United States, and one that turned Canadians into the second highest per capita users of prescription opioids in the world, after Americans. Some observers say that this is a side effect of Canada’s robust universal health-care system, though it can also be traced back to our historically poor regulation of painkiller dispensation.
In Ontario, which has the country’s highest per capita dispensing rate for high-dose opioid painkillers, the repercussions have been grave. Between 1991 and 2010, the province’s annual rate of opioid-related deaths jumped from 12.2 to 41.6 deaths per million; in 2010, one in eight deaths among people aged 24 to 35 were linked to opioids.
In short, Chatham-Kent is not alone, and Ontario’s painkiller problem has the hallmarks of an epidemic. The rise of prescription opioid misuse is the latest in an unending cycle of self-medication, regulation and drug market adaptation that may be immune to our efforts to control it. Our successes and failures in fighting Ontario’s painkiller epidemic, however, might just point to a way to end this cycle for good: by regulating illegal drugs the way we do prescription opioids.
I meet Lisa* in the offices of Chatham’s community health centre. Now 26, Lisa has been managing her painkiller addiction with the help of methadone for seven years, with some success: she’s enrolled in university and has regained custody of her three children. Beyond her manicured appearance and formal comportment, though, it is clear that she is still facing her demons. For Lisa, prescription painkillers have always been part of the landscape. “We would do Percocets in high school at gym class,” she says. As we speak, her mother sits nearby, a pained look on her face.
Christopher Cartier, a coordinator at AIDS Support Chatham-Kent, sees the epidemic up close every day. His job involves handing out clean needles and other supplies to people who use drugs, but at 24, he’s also young enough to know what it’s like to be a high school student in the prescription pill era. “I have noticed in the last few years that prescription drug use is increasing, especially among youth,” he says. “You go into your parents’ cupboards, and you grab their pills.”
This pervasive abuse finally prompted the federal, provincial and territorial governments to turn their attention to the crisis, but agreeing on a strategy has proven elusive. After years of mounting evidence that prescription opioid misuse was killing Canadians, Purdue Pharma Canada, the maker of OxyContin, announced in February 2012 that it would replace the drug with a new formulation, called OxyNeo. Later that year, the provinces and territories pushed Ottawa to restrict access to oxycodone-based pharmaceuticals by delaying approval for generic forms of OxyContin. But Health Canada went ahead anyway, arguing that federal laws didn’t allow them to prohibit a pharmaceutical because of misuse.
For Ontario, reeling from a mounting death rate (some statistics suggest that in 2012, more than 10 Ontarians a week were being killed by prescription painkillers), inaction was not an option. Shortly after Purdue heralded OxyNeo’s arrival, the province announced that, to limit prescription rates, the drug would be available only through the Exceptional Access Program and the Facilitated Access to Palliative Care Drugs mechanism. Purdue cannot claim that OxyNeo is tamper-resistant without approval from Health Canada. However, it is widely acknowledged that the new product was designed to be more difficult to break down and consume by snorting or injection. That means, in principle, that the potential for its abuse is limited, since its slow release wouldn’t satisfy opioid addicts.
The removal of OxyContin from the market is part of a larger approach, which includes an ID-based system to track opioid dispensation across the province in an effort to curb drug seekers from getting multiple prescriptions from different doctors. Still, taking crushable OxyContin off the menu hasn’t done away with the appetite for prescription opioids. “The constraints will cause people to find alternatives, just like any other kind of prohibition,” says Elliott. Economies, like nature, abhor a vacuum.
In Chatham-Kent, the local drug market moved into darker territory. The use of fentanyl-a drug that is 50 to 100 times more powerful than morphine, with a high risk of overdose death-increased. “A lot of the search warrants that we’re doing now are specifically for fentanyl,” says Const. Jeff Teetzel of Chatham-Kent’s Drug Enforcement Unit. According to the municipality’s police department, there have been seven deaths related to fentanyl misuse since 2011. But the shift away from OxyNeo wasn’t limited to fentanyl. Between 2012 (when OxyContin was discontinued) and 2013, the number of people charged with meth trafficking in Chatham-Kent increased, even though the overall number of people charged with drug violations decreased slightly.
The blowback of meddling with illegal drug markets is so well-documented that it has its own name in scientific literature: “the balloon effect.” The term comes from the way that poking a balloon in one place simply displaces the air elsewhere. Before OxyNeo was introduced, Lisa had a boyfriend who had suffered a back injury and was being prescribed huge amounts of painkillers-OxyContin, fentanyl and methadone. “All he took was the methadone,” she says. “He would sell everything else.” When OxyNeo replaced OxyContin, her boyfriend discovered he couldn’t sell it, so he claimed he had stomach pains and was unable to take the pills. “The doctor doubled him up on his fentanyl patches,” says Lisa, “and he was selling those.” According to Teetzel, just one patch is worth $400 to $480 on Chatham-Kent’s black market.
A recovering alcoholic, Gary* developed an opioid addiction after his wife suffered a herniated disc and he began dipping into her prescriptions. Within a few years, he was taking 16 to 20 Percocets and one to two Oxys a day-a habit he kept up for a half decade. By the time his wife’s prescription ran out in 2011, the volume of opioids that he had consumed made it physically impossible to quit cold turkey. With restricted access to opioids, Gary self-medicated with a familiar substance-alcohol. “By the end of it, I was bouncing from one addiction to the other to try to manage the withdrawal from either one,” he says. Aware that his family would suspect him if he smelled of alcohol, he sought other options, finally settling on 60 over-the-counter Tylenol pills a day. When that wasn’t enough, he got painkillers however he could, including stealing from a friend’s medicine cabinet. Gary’s alcohol abuse was much harder to conceal. The latest chapter in his battle with addiction began with an intervention from his wife and kids and a trip to the Westover Treatment Centre.
Opioid addiction, while painful and complicated, is possible to manage. One of the best tools we have is methadone maintenance therapy, an oral medication taken as a liquid. Methadone attaches to the brain’s opioid receptors and reduces the body’s craving for opium-derived substances like heroin and OxyContin. Although it has its limitations, methadone can be effective. It allowed Lisa to begin to rebuild her life.
The arrival of a methadone clinic is usually accompanied by not-in-my-backyard outrage. But a funny thing happened when Wallaceburg-a community of 10,000 people in Chatham-Kent riven by prescription opioid and meth addiction-opened not one but two clinics. “It’s an automotive-industry town where the industry has pretty much entirely disappeared, and there’s a high rate of unemployment,” says Janet*, Lisa’s mother. “And that’s led to the addiction rate being very, very high. So when the clinics opened, you didn’t hear a thing.” There are currently four methadone clinics in Chatham-Kent.
For his part, Elliott believes that any contingency plans put in place to deal with the symptoms of opioid addiction are likely to fail. That’s partly because his experience as a pharmacist exposed him to the profit motive that drives the prescription of these drugs in the first place. The same economic forces that allowed fentanyl to fill a void in Chatham-Kent’s diverted painkiller market, Elliott says, are spurring pharmaceutical companies to produce new opioids.
But the larger issue, he suggests, isn’t the motives of pharmaceutical companies-it’s a deep institutional reliance on opioids. Doctors are gaining a better understanding of the addictive potential of this class of pharmaceuticals. However, government drug plans tend to cover opioids but not alternatives or rehabilitative services such as physiotherapy, which would require private insurance or paying out of pocket. Until regulations change, Elliott says, communities like Chatham-Kent will be hard-pressed to stop the painkiller epidemic.
Our traditional response to illegal drug use has been based on a simple premise: if something is dangerously addictive, prohibit it. Prescription drug abuse adds a political complication to this scenario. While it may be easy to condemn crack or meth dealers, the situation is trickier when the substances in question are coming from your pharmacy. And when provinces put restrictions on OxyContin only to see the federal government later approve generic forms of the drug, there is little our criminal justice system can do.
The 1980s had crack babies; the 1990s had ecstasy raves; the 2010s have had breathless reporters claiming that taking so-called “bath salts” will make you eat someone’s face. Each Reefer Madness moment did little except further stigmatize drug users. But the prescription opioid problem has been different. We’ve seen humane policies that have the potential to stop prescription opioid diversion and abuse.
In Ontario, some of those policies have already worked. Every patient receiving prescription opioids gets an identifying number that allows the government to track dispensation patterns so that prescriptions don’t get out of control. The College of Physicians and Surgeons of Ontario has been working to educate physicians on safer pain management and advising the government on building policies to prevent diversion. And a new online tracking tool will alert Ontario health officials as soon as the number of opioid overdoses rises.
Still, there’s a disturbing corollary to this success story. Addiction can be surprisingly flexible. In Chatham-Kent, the balloon effect is in full swing. Even if painkiller diversion ceases entirely, it could very well be accompanied by a sustained shift toward other drugs.
So how do we tackle the frustrating fluidity of drug markets and the addictions they serve? The answer might lie in our policies around pharmaceutical dispensation. Despite lax restrictions, there is still a paper trail tracking every doctor-dispensed prescription, which ensures that all pills are accounted for. Once users shift to illegal substances, the paper trail ends. While we will likely see fewer people addicted to painkillers, we will also lose sight of what they’re turning to when prescription drugs run dry.
That’s why any strategy that focuses only on prescription medications is doomed to fail. Without addressing the root causes of addiction, the balloon effect will make sure that people who want drugs will find them. Narcotics laws have created illegal, multi-billion-dollar markets for heroin, cocaine, crystal meth and marijuana, all of which are outside of the purview of the state. The war on drugs has not made them disappear. Compare this failure with the flexibility of our policies around prescription opioids, which can be modified on the fly. The very fact that we regulate prescription opioids provides governments with policy options that can be put in place quickly to control their diversion. When these regulations are paired with a medical system that expertly recognizes and treats addiction, those who self-medicate can finally be helped to stabilize their lives.
But what if, instead of simply improving painkiller regulation, we made it the responsibility of governments to regulate heroin, crack and crystal meth? What if we could shape illegal drug markets using the same controls we use to shape access to prescription medications? Since Portugal decriminalized drugs in 2001, there has been a decline in drug-related deaths and fewer new cases of HIV among addicts, according to a report by Glenn Greenwald for the Cato Institute, a libertarian think tank in Washington, D.C. Of course, decriminalization is one thing; regulating illegal drugs is another. Even so, research has shown that regulating heroin under a prescription model can reduce users’ risk of death. A clinical trial conducted in Vancouver and Montreal, the North American Opiate Medication Initiative (NAOMI), provided 115 long-term heroin users with injectable diacetylmorphine (the active ingredient in heroin) in a medically supervised environment between 2005 and 2008. After a year, subjects reported improvements in medical and psychiatric status, employment, and family and social relations. Two-thirds of the patients also saw significant reductions in street-drug use or other illegal activities.
If our efforts to manage access to legal painkillers are successful, surely we should apply those lessons to all drugs. That means asking governments to assume control of the markets for illicit substances and instituting creative approaches, like the one pioneered by the NAOMI trial, to contain the harms they cause. While this gambit isn’t without risk, it may be the only way to puncture the balloon permanently.
As of 2013, according to a Global News analysis of health ministry data, prescriptions for OxyNeo in Ontario hover at around 25 per cent of what those for OxyContin were when it was discontinued. (In 2012, they were around 60 per cent.) Fentanyl prescriptions in the province, though, have remained relatively steady-between 20,000 and 25,000 a month-and the drug is still accessible. It will likely be some time before the flood of prescription opioids abates.
For Ron Elliott, tackling drug addiction comes down to a basic premise: have people ask themselves, “Why am I using?” If we can apply what we’ve learned about controlling prescription opioids to the entire drug market, we might finally be able to find the answer.
*Names have been changed.
© By Dan Werb. The Walrus (December 2014). thewalrus.ca