Last week, we broadcast our full-edition town hall entitled "Generation Rx - The Use and Abuse of Prescription Pain Medication," recorded before a live audience at Brockville Collegiate Institute.  Brockville, a small city in Eastern Ontario, was the setting for Ontario's first inquest into prescription opioid-related deaths.  My guests were Christine Bois, manager of the Opiate Project with the Centre for Addiction and Mental Health, Detective Staff Sergeant Shawn White, head of the Criminal Investigation Branch with the Cornwall Police, and Dr. Andrea Furlan, a chronic pain physician and scientist at the Toronto Rehabilitation Institute.  Not suprisingly, we received many, many emails from you.  Click on the link below to jump to your reaction to show.  And tune in on Tuesday, December 27 from five to six pm (half an hour later in parts of Newfoundland and Labrador) for an extended one-hour version of the show.

Heather Morgan writes:  "Thank you for your show on the use of prescription pain medication - Generation RX. It revised my anger once again that in this province (Ontario) prescribing pain medication is the only thing that doctors appear to have in their arsenal for treating pain. Instead of dealing with what is causing the pain, and dealing with the root cause, we throw pharmaceuticals at the problem and nothing more."

"I have a very direct experience with this. I had an induced labour with the birth of my son. I ended up with three epidurals and a C-section. The back pain that resulted was excruciating. My son is nearly three years old and I still suffer from terrible back pain. I asked my obgyn if there was some physiotherapy he could send me to. He said if I didn't have private insurance there was nothing that was covered. He wrote me - a new nursing mother - a prescription for oxycodone. I said "That's it? That is my only option?", "Unfortunately, yes", he replied. My back went out completely several times, to the point where I couldn't even stand up or walk, much less pick up by growing baby. My partner, who works freelance, could not afford to take any time off work, but was forced to since I was immobilized. I found an amazing chiropractor who used a number of different modalities to help me so that I could function again. But the cost was one hundred dollars per session. I needed many more sessions, but simply could not afford them."

"I wonder now if I will end up needing back surgery at some point.....clearly costing the health care system a great deal more money than had I been able to go through the full chiropractic treatment at the beginning of the problem. Or even if half of it was covered, I could have had twice as many treatments than I was able to afford.  Prescribing drugs to deal with certain types of pain, rather than addressing the source of the pain and trying to correct it, seems completely crazy to me, especially when there are vastly superior ways to deal with these varying types of pain, other than prescription opioids. Modalities that would SAVE the health care system money in the long term, and reduce the risk of abuse from prescription pain medication, thus saving society at large more money in the long run. If this growing problem doesn't demonstrate just how much we are under the thumb of the pharmaceutical industry, I don't know what does."

Tom Hickie of Fredericton, New Brunswick writes:  "Kudos for the program about OxyContin abuse this is a problem that has been rampant for a long time with little public attention. About six years ago I did my own research on the subject, I approached known drug users, prostitutes and others and asked them about their drug use. The common anwser was a bit of crack and dialaudid or oxycontin. One woman that I picked up hitch hiking was on her way to get some drugs from her son. One inmate in a provincial jail died from a drug overdose and five hundred pills were found concealed on his person. One company that produces this garbage was fined for hiding how addictive this drug is. The amount available on the street seems unusually high and I wonder if the companies are by passing the pharmacies. Another problem is that pharmaceutical sales people get paid to sell the drug, doctors get paid to prescribe it and druggists to dispense it and they are all protected by law, the sellers of cocaine would love such a perfect system. Our police chase marijuana and illegal smokes wth a passion while often ignoring this drug. Thank you for the show and please keep this topic public."

Deborah Cumming, National Priority Advisor with the Canadian Centre on Substance Abuse sent this:  "Thank you for showcasing this important public health crisis. As a follow up to your town hall on prescription drug misuse, I wanted to share with you that the Canadian Centre on Substance is hosting a national meeting with multsectoral stakeholders as the next step towards developing a national strategy on prescription drug misuse. This meeting will be held in Ottawa February 1-2, 2012."

Christine from Tatamagouche, Nova Scotia sent this:  "My ex-husband was prescribed m-eselon for moderate arthritis of the hip. This is an opioid that was covered by our insurance company. My ex-husband became addicted. He is a professional and for the powers that be was able to keep it hidden from his peers. My teenage son was not so lucky.  He stole the pills and snorted them. He became an addict. He was in rehab 6 times but to no avail. He was an above average student and athelete who dropped out of high school in the middle of his last year,and was the student body president and captain of the basketball team. He now lives with a daily struggle of addiction, with no high school degree.  My marriage failed.  I do not have a great relationship with my son.  My family was fractured by this.  It truly has been the biggest challenge of my life and does not get discussed as people do not wish or uncomfortable talking. Thankyou for listening."

Dr. Jon Archibald OF Peterborough, Ontario writes:  "Having been burned more times than I care to admit I have now changed my approach to pain patients: if they're not dying from cancer and I don't see physical trauma I won't prescribe any. That oversimplifies it but I no longer give patients the benefit of a doubt if there's no evidence of nociferous pathology on for example xrays.  There should be more specialists in pain management who will manage these patients ongoing, just as so many facets of general practice have become complex to the point of meriting their own expertise."

Louise Carbonneau Vermeiren of Port Stanley writes:  "I listened to your town hall broadcast and you captured my interests. You see, I am a chronic pain sufferer. It has affected my life and disrupted it, turning it upside down, backwards and forwards in so many ways, that at times, it would be easier to just give up and check out. No I am not depressed, not at all, this is just reality. And no, drugs are not talking through me, I no longer take opioids or anything else that can alter my moods, anymore."

Robert Rensing of Duncan, British Columbia sent us this email:  "I listened with great interest to your program about oxycodone abuse, and I would like to make two comments: Oxycodone containing medications are certainly not the only medications that can cause addiction and its terrible results. It is too bad that the discussion focused on those drugs alone to the exclusion of mention of other drugs that can cause similar addiction problems. It certainly would have been of help to us parents to become more aware of the dangers of a variety of other addiction-causing medications. There was much good talk about the need for young people, parents, and the medical professions, to become much more aware of those dangers. But what about the manufacturers who, through aggressive marketing by their representatives, contribute in a major way to the spread and availability of those medications. Do pharmaceutical companies not have ethical, moral, and social responsibilities to help educate doctors, not only in the appropriate use of these meds, but also to include specific education on the dangers of addiction, and practical ways to avoid those by prescribing appropriate strengths, dosages, and quantities of them? Has the time not come to educate the pharmaceutical companies about their responsibilities as well."

Donald G.McLeod of Mississippi Mils writes:  "The mother who lost her son to Oxycontin said a very wise think at the end of the show.  "Think twice before putting your hand into..."  Wise because hidden in her words acknowledges that kids do risky behaviour.  It is probably comes with evolution of we that tend to be either innately collaborative or innately selfish.   Neither is wrong, they probably are both good for the species depending on circumstances.   But her wise statement reminded me of an article on teenage brains I read about in Scientific America Mind edition.  Kids are too rational.  They think if the have sex they will definitely get a disease. But the benefit is still better.  They need to practice understanding risk.  Exaggerating risk is in fact bad.  It seems to allow them to exaggerate benefit as well.  I think maybe the show should talk about the teenage brain and the need to practice making risky type decisions."

Margaret Hawley of Calgary asked a practical yet important question:  "My interest is one of effectiveness of painkillers, particularly when they are used in palliative pain cases or following a major surgery. My husband had a major problem with hallucinations after taking morphine based drugs after open heart surgery.  Is there any alternative to morphine based pain killers for such cases? Have painkillers improved in effectiveness over the past 20 years?"

Margaret, opioid drugs like morphine are the most powerful pain relievers in the toolkit.  Lesser options for acute pain include anti-inflammatory drugs and acetaminophen (sold under the brand name Tylenol and other names).  The main issue with these other medicaions is that that have maximum doses above which have no added benefit and perhaps more side effects.  That said, opioid pain relievers are not effective for everyone. 

Regarding chronic pain, opioid pain relievers are usually prescribed in combination with antidepressants and anti-epilepsy drugs. 

Larissa Barr of Toronto asks:  "I was wondering if you have names of people who are willing to come in to schools and speak with students about this issue.  As a teacher I find it much more useful to have a diverse group of people speaking to students, rather  than the usual teacher talking to students.  Plus, I think many teachers may not talk to their students about drug use because they feel that they do not know enough, understand enough, or feel comfortable enough to talk to students about drug use...therefore names of people who would be comfortable talking and teaching kids about drug use/abuse would be helpful.   Thank you and great show."

Larissa, I would contact the local police as well as the Centre for Addiction and Mental Health in Toronto.

Not surprisingly, we also heard from critics of the show.

Karyn Collins of Ottawa took us to task for talking about kids sharing prescription drugs at parties.  She writes:  "I am almost incredulous that you are giving a platform to the urban myth of "Smarty Parties" and kids learning to take drugs from their obviously abysmal parents. I have no doubt that both have happened, but it totally undermines your credibility to broadcast these comments as though they were prevalent amongst teenagers today. The myth of Smarty Parties has been around since I was a teenager in the 1970s; everyone had heard of them but no one had been.  How many dead kids would you really have if this was common recreation?"

Karyn, our town hall included comments from Talia, a seventeen year old senior high school student who spoke with complete confidence about the buying and selling of prescription and illicit drugs where she goes to school.  Regarding the death rate, the overall number of prescription opioid-realted deaths, while small compared to the total prescribing of opioids, is on the rise, and is directly correlated to the increase in prescribing of opioids on provincial welfare entitlement programs.

Phil Rumble of London, Ontario thought the panel of experts was incomplete.  "I am normally a fan of your CBC radio program, however I must express my surprise. Your town hall program regarding opioid abuse did not feature a pharmacist on the panel!  Much of the discussion was regarding Oxycontin - a PRESCRIPTION only medication- and yet there was no pharmacist present. Health care will never become a "team" approach until all the "players" are present."

Marilyn Holt from Barrie, Ontario sent this:  "Two comments came to mind as i listened to your first town hall program, First, pharmacists should be part of this discussion. Although banning a drug such as oxycontin is not a sensible idea, surely there should be a limit on amounts prescribed. Despite the obvious inconvenience to patients, perhaps prescriptions of dangerous drugs should be limited in size, e.g. no more than twelve tablets at a time. What sort of doctor would prescribe one hundred tabs? What sort of pharmacist would fill that without checking. Second, there is some irony here for me. i'm a sixty-seven year old female and I've been plagued with severe headaches all my life. Mostly migraines, though not all. i take inderal on a regular basis but have never really found any of the migraine medications to work well. I often end up in emerg receiving injections of gravol/demerol.  My main problem has always been that my doctor wouldn't prescribe strong pain medication for me.  Very occasionally, she'd give me twenty Tylenol 3s, but never anything stronger. Honestly there have been occasions when I think I would have bought them on the street if someone offered them. That's definitely a 'tongue-in-cheek' comment, but refusal to allow pain meds can be ass dangerous as prescribing too much."

Ken Weatherill of Delta, British Columbia writes:  "I am a retired high school teacher who worked mainly with high risk youth.  I found the townhall broadcast to be very unbalanced.  Using words like addictive, epidemic, deadly, wide spread, out of control and ban  creates an atmosphere of  fear which the youth involved ignore and the majority cannot relate to.
Whenever a knowledgeable person came and spoke to a smaller group in a less formal setting with lots of opportunity for questions and comments, youth responded with attention and interest.  If adults create an atmosphere of judgement, youth will trust their friends. If adults create an atmosphere of trust and respect, youth will make good choices and call when needed rather than leaving things until they are really out of control. Without fail, after a small group discussion with and expert, there would always be one or two youth who would stay back and ask to speak with the presenter. Next time, bring a public health nurse, social worker, youth worker or counselor to a round table discussion with a grade nine class and record that interaction.  It will not only ensure a lively half hour but will also result in at least three more youth making better decisions at their next party."

Frances Abbott of Montreal writes: "I have done research on pain and analgesia for thirty-five years.  Overall, from family, friends and students, I have learned that undermedication  with strong analgesics is the rule, not the exception.  It took two years and the intervention of my medical brother to get my dad two OxyContin at bedtime for neuropathic pain in the feet.  Both my brother and I explained the objective of treatment to him many times - to improve function - and he finally got it, and is able to medicate for function."

"Overall, my impression is that most physicians knowledge of pain control could be written on the back of a matchbook.  I agree that the very concentrated slow release formulations are dangerous.  My understanding is that they should never be prescribed for conditions associated with pain that resolves in the short term.  In drug education, the message usually does not say enough about the pharmacology of the drugs.  From the police officer on your panel and others I have met, their focus is on trying  to scare teenagers.  They, and others who make their living off of drug control and research, try to magnify the problem.  There are certainly hundreds of people who do not receive sufficient opioid analgesics to permit function for every person taking illegal OxyContin."

And finally, some you thought the town hall completely missed the boat on explaining things from the point of view of someone with an addiction disorder.

Rick from Burlington, Ontario sent this email:  "I was intrigued that in your townhall you didn't include one addict as an expert on addiction. The people that where one the program have many valid points but really don't seem to understand the psyche of the people who become addicts. without that understanding the problem will never go away. Addiction is both physical and mental in nature. you can help someone withdraw from the physical effects of drugs but without that understanding of the mental, emotional nature of addiction, the addict will not be cured and will probably go back. I've been clean from alcohol and crack for twenty three years and understand our desire of a quick clean fix for the problem but it just isn't that easy and a few of the answers I heard I can guarantee would drive an addict further underground."

John from Ladysmith, BC writes:  "I'm a long time fan of White Coat, Black Art and will remain so as it's one of the best looks at medicine in Canada today that I know of.  It's not because of that that I'm appalled at the broadcast this past Saturday.  When I first entered recovery in 1983 one of the things I learned was that doctors got something like two hours of classes on addiction during their training.  From  both you, Doctor Goldman, and Dr. Andrea Furlan,who set the prescription guidelines, at least in Ontario, it doesn't sound that the situation has improved one bit.   None of the panellists touched on the complex dynamics of addiction, why people use, what the risk factors are of addiction and why people continue to use even though they KNOW it's wrong.  From Dr. Furlan's description of opiate withdrawal she may be an expert in pain management but she's not on issues like withdrawal because she horribly overstated both the length and severity of opiate withdrawal."

"I'm equally appalled at the parents of these kids as they don't seem to know to lock certain medications away from anyone it's not prescribed for, something I thought everyone knew and something routinely done by parents when I was a kid.  And no, things were NOT wonderful back then.  Nor was one of the simplest ways to avoid the first step of addiction (trying the drug) mentioned by any panels which is lock the darned stuff away.when the person it's prescribed for and, that, should any be left over after the course of treatment that the meds be returned to the pharmacist for disposal.  We aren't talking ASA tablets here! [smiles]. Addiction doesn't just happen.  There's a reason one of the slang words for dependency is wired.  Some receptors in the brain literally get to the point where they need the drug to function which is what we see in the physical manifestation called  withdrawal, as I'm sure you know.  The brain has literally rewired itself and withdrawal is symptomatic of, one could say, the brain madly rewiring itself to function without the drug of choice. The police officer, God bless him, had the same answers to the problem as they did 40 years ago when I graduated from high school and got my last "lesson" in how horrid drugs were."

"The single improvement there is his evident empathy for and concern for the addict other than the "write them off" attitude of police back then. Addiction is complex, as I mentioned.  It runs in families, if one goes by large numbers of twin studies done over the past two or three generations whether by a child being brought up in a highly dysfunctional family atmosphere or is an inherited thing.  I don't know, I'm not sure anyone does.  Though it seems that if a child is brought up in a family with one addict (and that includes alcoholism) they have something like a 40% chance of developing an addiction themselves when compared to the general population and where both biological parents are it increases to nearly 70%."

"Don't go overboard about the effects of withdrawal. Compared to other drugs it is very short and doesn't have all that much discomfort.  The patient needs to eat and drink but it's all over in less than a week, often less than 3 days.  Compare this to alcohol withdrawal which takes up to a week, has symptoms like the DTs and can be deadly unless medically supervised.  Or benzodiazapams which can take weeks or months. But opiate withdrawal is minor."

"I can say, without a word of a lie, that addicts and alcoholics are the strongest and, often, the most moral people I've ever encountered and their lives as thieves, prostitutes and liars had damaged them as much or more than the addiction itself.  There's a very good reason that when we reach the Step on making amends that, as a sponsor, I tell my sponsee that the first person on that list needs to be themselves.  After that making amends to others is more genuine and more likely to me met positively. By the way, people were breaking into drug stores to steal T3s long before more powerful opiate drugs came along.Thank you for a wonderful, informative and fascinating program."