Generation Rx: The Use and Abuse of Prescription Pain Medication
A generation ago, it was considered medical heresy to prescribe strong narcotics to people with chronic pain. But, a new way of thinking about pain made it more acceptable for doctors to prescribe these drugs. Along with that came the arrival of long-acting opioids like OxyContin, Duragesic, Hydromorph Contin and others - drugs that when used as directed, were supposedly less likely than short-acting narcotics to lead to addiction. I know, because I taught many doctors how to prescribe narcotics responsibly. And in the interests of full disclosure, some of those lectures were paid for by the very drug companies that stood to make large profits from the sale of the medication.
In properly selected patients, narcotics can reduce pain and improve their lives. But the tragic stories of lives ruined - if not lost - plus some alarming statistics show us that something has clearly gone wrong. That's why we've convened our town hall. To talk about the extent of the problem of opioid use and abuse, to find out how we got here, and to talk about what more can be done to prevent further addictions and deaths.
To hear the Generation Rx, download the podcast, or click on the play button below. You can also tune in Saturday December 3 at 11:30 am (noon NT) and again on Monday December 5 at 11:30 am (3:30 pm NT) on CBC Radio One.
And next week on the show, we'll have a bonus segment from the town hall about the role doctors have played. And listen for a full one hour version later this month - also on CBC Radio One. More details about that soon.
The Scale of Prescription Drug Abuse
Prescription drug abuse is a major public health problem in Canada today. In fact, Dr. Andrea Furlan, a pain specialist at Toronto Rehabilitation Institute and one of the major drivers of the development of safe prescribing guidelines, called it "an epidemic".
"It's so bad because this is what we call an epidemic caused by physicians. It's an iatrogenic (meaning caused by physicians) public health problem."
The non-medical or recreational use of prescription drugs is now the fourth-leading cause of substance abuse in Canada, behind alcohol, tobacco and marijuana. Accidental and deliberate misuse of these drugs is now a rising cause of deaths here as well. Since 2004, in Ontario, the number of deaths in which the drug oxycodone - the active ingredient in OxyContin - was a factor has nearly doubled. In 2008, there were 327 deaths in Ontario in which prescription narcotics were a factor; in 148 of those deaths, oxycodone was a factor.
Why Hold Generation Rx in a High School in Brockville?
We held Generation Rx at Brockville Collegiate Institute because Brockville, a town in Eastern Ontario, was home to Ontario's first inquest into two deaths related to opioid pain relievers. Three years ago, Dustin King, a nineteen year old at the time, snorted a combination of marijuana, cocaine and crushed and snorted half a tablet of OxyContin. By next afternoon, he was dead. Less than two weeks later, his friend Donna Bertrand, a 41-year old former nurse, was also found dead in the same apartment. We chose a high school because of the growing problem of prescription opioid drug abuse among teens.
"They feel it's safe," said Brenda Toupin, mother of Dustin King, at Generation Rx. "It's in their own parent's medicine cabinet. And what parents are not realizing is the fact that drugs like this are locked in a pharmacy. They should be locked in their home."
We heard from one young man who told of a 13 year old who was being taught by his dad how to shoot up prescription narcotics. We also heard about teens having "pill parties" in which they bring all manner of controlled substances pilfered from various sources into a large bowl. The bowl is passed from teen to teen; participants are asked to reach into the bowl, grab a handful of pills and swallow them, without knowing what they've taken.
"In fact, when we looked at grade eight students," said the Centre for Addiction and Mental Health's Christine Bois, "almost eleven percent of these students have used these drugs recreationally, and that's shocking."
Roots of the Problem
Are patients aware that they're taking a medication that comes with considerable risk? To me, it's striking just how unaware patients are of the risk. At the town hall, we heard from people who say either they or a family member became addicted to OxyContin and other narcotics but never had any warnings from their doctor that it could happen. We also heard from a woman who said she broke her arm and was given a prescription for oxycodone and said she too was never told there was a risk she could become hooked. We heard that dentists increasingly prescribe strong narcotics when they take out wisdom teeth and other dental procedures. Chrisine Bois of the Centre of Addiction and Mental Health said stories like these are the rule and not the exception.
"I think it's because these drugs are readily available," Bois said at the town hall. "Most of us probably have them in our medicine cabinet. We may have a Tylenol #3 prescription that's sitting there and we may not have used it in a while. But also, most of us don't understand that these painkillers are not like an Aspirin. We don't know that they have a lot of hazards and it's dangerous to mix them with other drugs such as alcohol. Most of us don't know that if we take one of these drugs for three weeks daily, you can become physically dependent."
Whose fault is it that patients aren't aware of the risk? Narcotics are what we call controlled substances. By law, these can only be prescribed by licensed health professionals, including doctors, dentists and in some provinces nurse practitioners. Whenever you prescribe a drug, you have to tell the patient what the drug is for and what the risk is. It's clear that some (maybe a lot) of MDs haven't been doing their job.
A big reason for this is a lack of education in the assessment and management of patients with chronic pain. Although things are changing, it's not uncommon for medical schools to have one or two hours at most on the subject of pain and its treatment. In the absence of unbiased learning, drug companies stepped into the breach -- providing industry-sponsored lectures and educational materials.
Before I ever gave an industry-sponsored talk on pain management, I was an expert in what's known as prescription drug diversion -- the procurement of opioid pain relievers prescribed by a doctor and dispensed by a pharmacist and sold on the street to drug dealers and addicts plus recreational drug abusers.
That said, having given some of those drug company sponsored talks myself, I always warned doctors about the risk of addiction and diversion. However, I don't think I talked about the risk in the same worrisome terms as I would today. It may be because we have a lot more evidence of addiction and death today than we did back then.
Sadly, lack of education may have led some doctors and other health care providers to prescribe excessive quantities of prescription narcotics, says Dr. Andrea Furlan, who spearheaded the development of national guidelines for doctors on safe prescribing.
"Within the guideline, there is a protocol how to stop this medication because they learn how to start (prescribing) but they don't learn how to stop," Dr. Furlan told Generation Rx. "And the withdrawal symptoms are so serious and so bad, the patients don't want to stop."
For the patients who do succeed at quitting, there may be another problem: a sizeable quantity of leftover pills.
"I had this boyfriend who was working on a roof once and his doctor prescribed him eighty milligrams of OxyContin," grade twelve student Talia told Generation Rx. "I remember thinking how are people (who) I know getting them. And I realized once I left him that people like him are realizing they aren't facing this pain anymore and they're going to get rid of them."
Unfortunately, with leftover pills comes a market.
"The doctor prescribes OxyContin forty milligrams and gives the patient a hundred tablets," says Detective Staff Sergeant Shawn White of Cornwall Community Police. He's considered an expert in the field of opioid diversion in Eastern Ontario. "They may take four or five of those hundred tablets for their pain. But what they turn around and do is sell the ninety-five they have remaining. They may be on the Ontario Drug Benefit Plan, which means they pay three dollars for that medication."
Detective White says the drug seekers can sell the leftover forty milligram tablets to drug dealers for up to forty dollars a tablet.
"That's almost four thousand dollars," says Detective White. "That's pretty good profit for somebody who may not have a lot of money coming in. And that's just feeding a large supply of OxyContin to be sold on the street."
After all we heard at the town hall, you may be surprised to learn that the panel of experts were unanimous in saying that banning strong prescription narcotics will not end drug abuse. Doing so will punish legitimate pain sufferers and will only encourage addicts to experiment with other drugs.
There is hope that a new narcotic formulation that can't be crushed and injected or snorted will help reduce drug abuse. However, that sort of strategy - while reducing the risk of accidental or deliberate ingestion of a dangerously high dosage of drug - will not prevent drug seekers from simply consuming a large number of tamper-proof pills. And it won't stop clandestine chemists from searching for ways to circumvent the tamper-resistant formulation.
Dr. Andrea Furlan, who developed prescriber guidelines for health professionals, says there needs to be some way to compel doctors to read them and practice by them. Several states in the US have compulsory education programs for would-be prescribers of controlled substances.
If doctors aren't warning patients about the risks of prescription opioids and other controlled substances, then maybe it's necessary to talk directly to those most at risk.
"I think we need to do more," Christine Bois told Generation Rx. "Most schools don't have any modules for the teachers to talk to their students about these drugs at all. They'll talk to them about alcohol. They'll talk to them about sex. But they're not talking to them about these drugs."
"We live in a society where if you have a sore back, you take a pill," said Detective White. "If you have a headache, take a pill. If you don't feel well, take a pill. And one of the recommendations that we would like to see is that it be part of the school curriculum. We believe that by Grade Six, kids need to be educated."
"This has to be just as important as math and science. If you look at the number of people who will suffer from addiction in their life time, it is important that we educate them on the dangers of that."
Sad to think Detective White is right, but he is.