Ontario Cracks Down on

Prescription

NARcoTIcs
By Ryan FOrd

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When OxyContin rst appeared in Canada, it was a revelation for pain sufferers. Just one pill could provide much needed relief for up to twelve hours. Most importantly, they were not habit-forming or so it was thought. In its wake other prescription narcotics, or opioids, have poured in. Since the rst introduction of these miracle pills, Ontario has become the largest user of opioids in Canada, with prescription rates for oxycodone drugs rising nine hundred percent since 1991. Deaths connected to oxycodone use have doubled since 2004. Prescription narcotics are now the third most commonly abused substance in Ontario, ahead of tobacco and behind only alcohol and marijuana. Prescription narcotics have become so ingrained, and affect so many different areas of the health sector, that even dening the problem is troublesome. The Problem Part of the problem has been misinformation. Early claims and socalled proof downplayed the risk of addiction, but it quickly became apparent that oxycodone drugs were highly addictive. In 2007, a US judge ned Purdue Pharma, the makers of OxyContin, $600 million for misleading the public about the risk of addiction. In addition, three P28 | YOUR HEALTH AND FITNESS MAGAZINE | LONDON

of the companys executives were ned a total of $34.5 million, also for misrepresenting their product, and were sentenced to four hundred hours of community service to be served in drug treatment centres. Yet in 2008, OxyContin sales topped $2.5 billion in the US alone. Part of the problem is economic. Readily available, inexpensive, easy to use and abuse, opioids have destroyed many of the lives they were originally intended to aid. A $4 pill sells for $40 on the street, and as much as $120 in some remote First Nations community. Especially a problem there, several chiefs have declared states of emergency over opioid abuse. In a presentation to the Parliamentary committee developing Ontarios new prescription narcotics legislation, Janet Kasperski, the CEO of the Ontario College of Family Physicians, notes that People can address the needs of their family living in poverty simply by selling the drugs obtained for [their] own pain problems. The result has put pharmacists at risk, with robberies on the rise to the point that some pharmacies no longer keep opioids in stock. Rather, theyre available only by special order, further burdening patients legitimately trying to manage their pain.

Part of the problem is communication, leading to double-doctoring or poly-pharmacies. Without a centralized database for monitored drugs, doctors and pharmacists have a difcult time determining who has been prescribed how much of what. Right now we have no idea who else is prescribing an opioid for a patient unless the patient or another physician tells us, says Dr. Dwight Moulin, Professor of Clinical Neurological Sciences and Oncology, and Earl Russell Chair of Pain Research at Western. If we suspect double-doctoring, its enormously time-consuming. We have to call all the various pharmacies and get the records from them, if we can even nd out which pharmacy theyve been to. Sometimes we have to call the family doctor and nd out which pharmacies this person uses, and then we might nd out theyre getting the same drug from me and their family doctor or they go to a walk-in clinic. Other communication issues can cause difculties as well. Sometimes patients lie; sometimes a language barrier interferes; sometimes busy doctors can make mistakes on charts; any number of factors can cause doctors to overreact to prevent double-doctoring, thereby disrupting legitimate pain management, or allow disreputable patients to dupe doctors. Part of the problem is the nature of pain. Pain is subjective and difcult to quantify; not everyone experiences it in exactly the same way. Just as everyone has different thresholds for pain, no one method of pain management works for everyone. The problem is we can never predict whos going to benet and who isnt, says Moulin. Its mostly trial and error. Some people benet enormously and are able to get on with their life. Part of the problem has been a lack of education. Some doctors havent asked the right questions before prescribing an opioid. Patients should be thoroughly screened before being prescribed these drugs, according to Moulin. If theres a past history of substance abuse, or a major psychiatric or personality disorder, or family history of substance abuse, or other individuals living in the house with a history of substance abuse, those are all relative contraindications of starting someone on an opioid, he says. When properly screened, patients should be at little risk of developing opioid dependence. People under the age of forty are at greater risk, he continues. If somebody is over the age of forty or fty and theyve never abused drugs in the past, and dont have any of the risk factors Ive just mentioned, the risk of becoming

drugs as a drug of choice. Speaking to people who work in addictions, I heard the same message from them: they were seeing more and more people coming for help for addiction to prescription narcotics. Another contributing bit of information was from the coroner, who reported that the number of deaths related to prescription narcotics was increasing dramatically. So all of these things were contributing factors to us taking a really serious look at what we were doing and what we could do. Finding the will to act was only the rst step. The Ministry of Health pulled together an expert panel with representatives from all the different sectors being affected by opioid abuse and developed a robust approach to this many-headed problem: The Ontario Narcotics Strategy. Unveiled in London in August of 2010, the main thrust of the strategy involves education for patients in usage and health practitioners in prescribing and dispensing opioids, and increased emphasis on treatment of addictions. To give the strategy some teeth, it will be backed up with new legislation: The Ontario Narcotics Safety and Awareness Act, 2010. While still in its early stages, the Narcotics Strategy has been well received as an important rst step.

Misuse and abuse of prescription narcotics does not just impact ones health, said Ian Peer, Deputy Chief of London Police Services, in reaction. It impacts public safety in many Ontario communities. I am very pleased to see the province bring forward the Narcotics Strategy which will help to address the misuse and abuse of prescription narcotics and controlled substances. The legislation allows the Ministry of Health and Long-Term Care to track narcotics and controlled substance prescriptions in Ontario, and keep personal health information in a provincial narcotics database. It also requires prescribers and dispensers to record specic information on prescriptions for monitored drugs, and requires dispensers to verify the identity of medication seekers before dispensing monitored drugs. Prescribers, dispensers and operators of pharmacies will be required to disclose information related to prescriptions for monitored drugs to the Ministry of Health when requested, and the legislation establishes offences and penalties for non-compliance. However, the legislation will not apply to patients receiving in-hospital care who are prescribed monitored drugs as part of their treatment.

Connecting prescribers, dispensers, and patients is the cornerstone of the legislation, says Matthews. We will be able to, in the future, identify those physicians who are prescribing very high amounts of narcotics. We know anecdotally about some of them, but this will actually give us that information; it will tell us which pharmacies are dispensing very high amounts of prescription narcotics without asking the questions theyre supposed to be asking; and it will give us the information we need to identify those who are really abusing prescription narcotics. With the legislation having received Royal Assent, attention has turned to creating the provincial database that will accomplish that goal. What it means is that well be able to see those patterns of outliers, whether its the prescribers or dispensers or the individuals, says Matthews. Then well be able to report that information to the Colleges so they can take appropriate action, and in the extreme cases, to law enforcement. In September of Physicians and released its own Abuse, Achieving 2010, the College of Surgeons of Ontario report, titled Avoiding a Balance. For the

addicted is low. Only about ten percent of the population is biologically predisposed to addiction. So with proper screening, the risk of somebody showing this aberrant drugrelated behaviour is actually very small. Part of the problem is the effectiveness of opioids; they have revolutionized health care. Prior to their introduction, powerful painkillers were primarily injected, which necessitated nursing care and supervision. However, with patients able to administer their own longlasting medication, day surgeries became possible. Even dentists could use oxycodone drugs to help their patients manage their pain. Not only that, but opioids have few detrimental effects on the body. They dont cause any organ damage at all, says Moulin. They dont affect the liver or the kidneys or the heart in any way. They can soften the bones over the long term, so this needs to be monitored and sometimes treated with calcium and vitamin D supplements and other agents. They can also affect sex hormones and decrease libido and sometimes hormone supplementation is necessary, but otherwisetheyre relatively safe drugs. Opioids are simply too important to purge from the system altogether. Part of the problem is treatment. In her presentation, Kasperski writes that Family physicians faced with a patient who needs pain relief to get on with their life feel compelled to sign that prescription pad; however, when they begin to realize that the patient has become addicted to the drug that provided them with the acute or chronic pain relief they needed, there are few services available to help them wean the patient off the drug. A life spent going to a methadone clinic is really not the answer. In London, Addiction Services of Thames Valley has

just six counsellors for its substance abuse program, serving a city of about 380,000. The Solution As it became clear that Ontarians had a drug problem, governments were slow to react. Doctors, somewhat intimidated by or undereducated about these powerful drugs and the care they require, sometimes watched helplessly as patients became addicted, or shied away from prescribing a potentially helpful painkiller altogether. The stirrings of a solution started in London. Minister of Health Deb Matthews points to one momentous ridealong to Londons East End as the origin of the provinces narcotics strategy. That afternoon I learned, rst of all, that virtually all sex trade workers are addicts, and that their addiction came before their involvement in the sex trade, and that much of the addiction is to prescription narcotics, says Matthews. I actually met a woman who, three years earlier, had been living the normal, suburban Mom life she had kids, drove a minivan, had her own business and got prescribed narcotics for legitimate reasons, but was unable to get off them. In fact, her addiction increased, and she lost everything. She lost her business, she lost her family, and she had gone from a small business owner to a sex trade worker in a matter of a few years as a result of prescription narcotic use. So then I started looking for more information and asked the Ministry of Health to look at the issue, she continues. They started to investigate and they discovered that Ontario has one of the highest rates of narcotic usage anywhere in the world. Then, in talking to police and law enforcement, it became clear that a lot of these drugs were being sold, overtaking other street

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report, the College assembled four working groups composed of health professionals, regulators, community groups, law enforcement, government and other stakeholders. Their work produced thirtyone recommendations, including creating a coordinated, accessible system for the treatment of pain and addiction; taking immediate steps forward to make greater use of technology to improve outcomes for patients and reduce diversion; enhancing the training and ongoing education of health care providers and improving education and awareness of the public; and empowering health care professionals, institutions and law enforcement agencies to reduce diversion by facilitating information-sharing and establishing a duty to report criminal activity. Opioid abuse has been recognized as a national problem as well. In a signicant step towards consistency, and to help educate health practitioners, all of the provincial colleges of medicine, as well as the Federation of Medical Regulatory Authorities of Canada, the Government of Nunavut, and the Yukon Medical Council, came together to develop national guidelines for safe and effective opioid use. Their report was published in April of 2010. The guidelines provide detailed, step-by-step instructions for physicians on when to prescribe opioids, what signs to look for to determine opioid dependence or diversion, what to do if dependence or diversion is suspected, and information patients prescribed opioids should know. With that kind of consistent message and a united front from government, regulatory bodies and professional organizations, Ontarios drug problem is nally receiving the attention it sorely needs. Left unaddressed for years, only the dishonest proted, with patients in pain often getting hooked or being treated with suspicion, pharmacists increasingly put at risk of crime, and the resources to deal with addiction failing to keep pace with the growing rates of addiction. Now, with a dedicated, comprehensive strategy, Ontario can start down the long road to recovery. Its a trip that began in Londons East End. Since then, The more questions I asked, the more Ive learned, and since weve brought the legislation forward, I sadly have spoken to many parents who have lost children to prescription drug abuse, and its just tragic, says Matthews. Im very happy that were moving forward and taking steps that will prevent that.

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