Commentary: Doctors inadvertently turning patients into addicts

August 20, 2014 – In my first career as a pharmacist, I worked in more than 30 pharmacies across Nova Scotia, filling more than 100,000 prescriptions between 1990 and 1995. Some of these were for strong painkillers called opioids – drugs like morphine and oxycodone, which are chemically and biologically very similar to heroin. Back then, these drugs were generally reserved for patients with acute, severe pain or pain due to cancer.

Twenty years into my second career as a physician, much has changed.

In Ontario, about 10 people die accidentally from prescription opioids
every week, often in the prime of life. Across Canada, overdose deaths
have risen and addiction rates and demand for treatment have
skyrocketed.

This happened because doctors began prescribing
opioids more liberally for patients with chronic pain. Sometimes this
leads to meaningful improvement, but frequently it does not. By the time
failure is apparent, patients are often 'opioid dependent,' meaning the
body has come to expect the drug and will revolt violently if it is
stopped. And so opioid treatment is continued – and doses escalated – in
a dangerous, often futile search for relief.

We are now in a
very difficult position. On one hand, we have millions of chronic pain
patients seeking help, often in the form of a prescription. On the
other, we have an epidemic of addiction and death. The false notion that
opioids are safe, effective treatments for chronic pain was inculcated
by the companies that manufacture them, with self-styled ‘experts’
preaching this gospel to frontline physicians. Incredibly, this happened
in the absence of good evidence that the benefits of long-term opioid
use outweigh the risks.

The United States and Canada have both
declared prescription painkiller public health crises – in the U.S.,
about 17,000 people die each year from the drugs. But the countries have
reacted very differently. In 2007, Purdue Pharma pleaded guilty in the
United States for misleading doctors about OxyContin, a felony
accompanied by a $634 million fine. No similar action occurred in
Canada.

In 2011, a major White House report acknowledged
prescription drug abuse as the country's fastest growing drug problem,
establishing goals and timelines for addressing it. The U.S. Centers for
Disease Control and Prevention tracks opioid deaths and prescribing
nationally, and describes how some states have managed to reduce
prescribing.

In contrast, there is no national system of
surveillance in Canada, and even the number of Canadians who die
annually from opioids is unknown. The federal government recently handed
responsibility for tackling the epidemic to the Canadian Centre for
Substance Abuse (CCSA), an inadequately resourced non-governmental organization
funded primarily by Health Canada that also addresses the abuse of
alcohol and illicit drugs. In 2013, an advisory council to the centre
produced a 10-year strategy to combat the opioid crisis, but its 58
recommendations were not prioritized (as they surely should be), and are
to be implemented by volunteers from other organizations.

In
February, the federal government announced funding to address
prescription drug abuse as part of the low profile National Anti-Drug
Strategy, a group headed by the Department of Justice and historically
undermined by restrictions on information sharing. These initiatives
give the regrettable impression of being ornamental rather than
substantive.

We now face a public health crisis of exceptional
scale – an epidemic fueled by well-meaning doctors, expectant patients
and corporate interests, and perpetuated by governmental inertia. While
we await federal and provincial interventions of substance, some
pragmatic solutions have already been suggested.

Doctors need
better education, independent from the pharmaceutical industry,
regarding pain and its treatment. We must start prescribing opioids more
cautiously; otherwise, nothing will change. A national assessment of
the toll exacted by opioids is long overdue. (How can we fix a problem
we don't even measure?) Every doctor and pharmacist should have
real-time access to a patient's full medication profile, as has been the
case in British Columbia for almost two decades. Drug companies should
be compelled to conduct large-scale evaluations of the benefits and
risks of their drugs, rather than small studies aimed at getting their
products to market. Patient and physician registries should be
implemented for high-dose opioids, facilitating targeted interventions
intended to maximize benefit and minimize harm.

Finally, we need
better treatments for pain, including drugs that alleviate pain safely
and effectively. This is a lofty long-term goal. Until then, we must
collectively lower our expectations of what pills can do for patients
with chronic pain. Unless that message sinks in and a measure of respect
for opioids resurfaces, these drugs will continue to cause immeasurable
harm.

This article was originally published in Troy Media – www.troymedia.com

Read the CCSA's Letter to the Editor in response to Dr. Juurlink's article.


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David Juurlink is an expert advisor with
EvidenceNetwork.ca and Professor and Head of the Division of Clinical
Pharmacology and Toxicology at the University of Toronto. You can follow
him on Twitter at @davidjuurlink