Saturday, November 14, 2009 – Globe and Mail
ANNA MEHLER PAPERNY
Janey Nagle wasn’t looking for kicks when she began courting a drug habit. The Percocets her doctor prescribed were the only thing that could take away the excruciating pain that lingered a decade after a car accident threw her into a windshield with such force that her face left an imprint in the glass.
For the first two years, the painkillers did the trick. The Perth, Ont., mother of four was able to work and look after her family. But after a while she couldn’t get through the day without the pills’ euphoric effect, and that demanded higher and higher doses.
Fearful her doctor would cut her off, Ms. Nagle looked elsewhere. She spent hundreds of dollars a day on prescription drugs bought off the street, primarily from friends and acquaintances. She photocopied her prescriptions and filled each one repeatedly at pharmacies around Perth, Kingston and Smiths Falls.
“It was a horrible, panicked feeling every morning when I woke up,” says Ms. Nagle, now 43. She remembers the daily dilemma: “How am I going to get them? Where am I going to get the money?”
This went on for years before she was caught at a drugstore and charged with forgery.
Like Ms. Nagle, Canada has fallen quietly into the grip of a pill problem in the past decade. Medications designed to treat pain and anxiety are creating legions of accidental addicts from coast to coast. In Regina, it’s morphine; in Toronto, OxyContin and Percocet; in Edmonton, OxyContin, various benzodiazepines and the whole Tylenol gamut.
At a rate of more than 466,000 doses a day, Canadians pop more painkillers per capita than almost any other country (topped only by the United States and Belgium). Spending on prescription opioids more than doubled from 1998 to 2007, and prescription-opiate abuse grew an estimated 24.3 per cent from 2002 to 2005, according to a study published this year in the Canadian Journal of Public Health – while heroin consumption fell 6.5 per cent.
The federal government’s national anti-drug strategy has spent tens of millions of dollars on prevention and enforcement initiatives, targeting the country’s most hard-core heroin, methamphetamine and crack addicts.
But the fastest-growing group of addicts doesn’t fit that mould: They’re getting drugs from pharmaceutical shelves or buying pills on the street in transactions police have difficulty preventing because the drugs themselves are legal.
In 2000, less than 4 per cent of the opiate addicts in withdrawal treatment at Toronto’s Centre for Addiction and Mental Health (CAMH) were addicted to oxycodone, the primary ingredient in such prescription drugs as OxyContin, Percocet and Percodan. By 2004, that figure had climbed to 55.4 per cent.
The problem is complicated by what CAMH doctor Curtis Handford calls an “epidemic of chronic pain” in a stressed and aging population, and doctors “whose options to treat that condition are limited. They have an inundation of marketing and guidelines telling them that opioids are a legitimate treatment choice.”
Under those conditions, he says, doctors can be too indiscriminate in their prescriptions and not careful enough about monitoring patients at risk of addiction.
Across Canada, this crisis is prompting medical authorities to study changing the way these drugs are controlled and policed. But some observers question whether these steps will be enough to get the prescription-drug monkey off the nation’s back.
What begins with pain-suffering adults often gets picked up by thrill-seeking youth. A 2007 survey of Ontario students found that more than one in five had taken painkillers that weren’t prescribed to them at least once in the past year. This could mean something as innocent as sneaking a pill from a friend’s medicine cabinet, notes Jurgen Rehm, a senior scientist at CAMH. But it’s indicative of how prevalent and acceptable prescription-drug abuse has become.
“We know that prescription-opioid abuse is the main mode of drug abuse among street kids and street drug users in general,” Dr. Rehm says. “We know from the U.S. that there’s a parallel between the abuse and the availability of prescription opioids.” He adds: “We had been concentrating so much on heroin. … We always thought that [pills are] just the lesser evil.”
But that view is out of date. In preparation for a groundbreaking study on heroin treatment in 2004, doctors in Toronto ran into a bizarre problem – there weren’t enough heroin addicts.
“We did a feasibility study … and within several months we couldn’t find any patients,” Dr. Rehm says. “We do not have people who are predominantly, or mainly, or even with a regular frequency injecting heroin as their main drug. … They don’t exist.”
The picture is similar across the country: A 2006 study found that the only two places in Canada where heroin abuse outpaces that of prescription opiates are Vancouver and Montreal – port cities that are hubs of the global drug trade.
Everywhere else, pill popping (or grinding pills into a waxy powder, to inject for a better high) is the order of the day. An estimated 30 to 40 per cent of the 1,000 to 2,000 overdose deaths in Canada each year may be related to prescription opioids.
“How common is it?” says recovering addict Sean Winger, 29. “Really common. I was driving to the store the other day and there was a group of five kids. … I could hear, ‘Oh, those aren’t Oxys.’ ‘Well, what is it? How much do you take?’ They don’t know what they’re taking.”
‘Everybody starts swallowing and snorting’ Mr. Winger got his first taste of prescription drugs at the age of 17, when he got his wisdom teeth out and was prescribed Percodan for the pain. The Kitchener, Ont., resident has been chasing that same high ever since: “My depression went away, it gave me energy, it made me sociable.”
A little while later, when his employer at a landscaping company was hard up for cash, she offered to pay him in the OxyContin pills she had been prescribed for chronic pain. “Was it responsible to pay an 18-year-old kid with OxyContin? Probably not,” Mr. Winger says, but he was only too happy to oblige.
When his employer’s pills weren’t enough, it was easy for Mr. Winger to find friends, or friends of friends, selling their own. As his craving grew, he looked up instructions online and filched needles from his diabetic grandmother to inject.
“Everybody starts swallowing and snorting … but it’s just a matter of economy by then: You get so much higher with injecting that I couldn’t afford to snort.”
He would get out of bed and mix his usual – one-and-a-half 80-milligram pills of OxyContin, ground up and injected into his left arm – and “that would be like my wake-up.”
In the five years Mr. Winger spent hooked on OxyContin, he held down a full-time job. He had a long-term girlfriend and a supportive extended family. He took classes at the University of Toronto. “I was a functional addict.”
But by the time he checked himself into a methadone clinic at the age of 23, Mr. Winger weighed 145 pounds, had collapsed a vein and added vomiting to his morning routine. He had broken up with his girlfriend, moved in with his grandmother and “was trying to decide if I had enough Oxy, if I injected it all, if it would be enough to kill me.”
In many ways, prescription drugs are less dangerous than other addictive substances: They’re legal and their manufacture is regulated, so if you know what pills you’re taking, you know what’s in them. But because of their easy availability and that very lack of stigma, they are a far more insidious cause of addiction.
Such woes may be most common in smaller communities that are less likely to have the resources to cope. A University of British Columbia study has found that people in B.C.’s smaller towns are disproportionately dependent on prescription drugs.
Steve Morgan, one of the report’s principal researchers, says painkiller use also seems to be higher in places – the B.C. Interior, Alberta’s oil-sands region and Ontario’s manufacturing heartland – with a higher number of workplace-related hazards.
“Could it be the case that occupational hazards lead to opiate addiction? … This is something we need to be studying.”
Approaches used with drugs such as heroin can be ineffective. Right now, methadone clinics are full of prescription-drug addicts who in many cases are not getting proper treatment.
When powerful painkillers first came onto the scene in the late 1990s, addiction was not even discussed, says Clement Sun, a doctor at a methadone clinic in Toronto’s east end. “They simply said, ‘Here’s a pill, it’s good for pain.’ … We didn’t even know how addictive it was.” When a patient got hooked, “the doctor would just say, ‘No more’ and they were cut off. Now, what does a patient do when they withdraw? … They go out on the street.”
The challenge is to motivate doctors to retrain
There are, at last, some major initiatives under way in Canada to tackle prescription-drug abuse.
Ontario’s College of Physicians and Surgeons and the Ontario provincial government each have convened panels of doctors, police, pharmacists and coroners.
At the same time, the National Opioid Guidelines Group, with more than 100 physicians, researchers and practitioners from across Canada, has been working out the country’s first-ever parameters for doctors on when to prescribe opiates, which drugs to choose and how to tell if a patient is at particular risk for addiction.
Although the guidelines will not be binding, they are certainly a step forward, says the group’s co-chair, Clarence Weppler, manager of physician prescribing practices for the Alberta College of Physicians and Surgeons.
But other jurisdictions have moved far more aggressively. California, for example, obliges doctors to get regular opioid-prescribing training or risk losing their licence.
A few provinces, such as British Columbia, record the medications their physicians prescribe and can track patterns of which doctors are giving out what, which patients are shopping around for multiple prescriptions and which patient deaths can be linked to prescription opioids.
But that is more a service for doctors than a policing mechanism, says W. Robbert Vroom, deputy registrar of B.C.’s College of Physicians and Surgeons. “If a patient goes to five physicians in a one-month period for large amounts of opiates, we send letters to these physicians,” he says. “We’re not pointing fingers, saying, ‘Your patient has an addiction problem.’ “
But Doug Gourlay, a pain and addiction specialist at CAMH and Toronto’s Wasser Centre for Pain Management, argues that mere directives do not go far enough. “Guidelines can be helpful, but, again, they are just that – guidelines,” he says.
Many physicians say a California-style approach would not fly in Canada’s public-health system. Forcing doctors to take time to attend prescribed classes would be deeply unpopular.
But Dr. Gourlay says that “in medical school and in our training, most of us aren’t given much education around the challenges of discontinuing the opioid class of drugs.”
For that reason, providing training to practitioners may be crucial. “The challenge,” Dr. Gourlay says, “is in making it worth a clinician’s while to do this.”
Ultimately, Dr. Vroom says, physicians need to be part of the solution. “We can’t enable addiction.”
‘I should have been supervised more’
Ms. Nagle’s husband knew nothing about her problem until he was called to the pharmacy when she was arrested in 2007. “When he found out how bad it was, it was like being hit over the head.”
She was given 18 months’ probation and eventually enrolled in a methadone and counselling program. She has been off the other drugs for nearly a year, and her two youngest kids (10 and 13; her oldest is now 23) are still largely in the dark about the whole thing.
But she wonders why her doctor, who knew she had a history of alcohol problems, did not ask more questions before putting her on Percocet long-term. And she asks why he kept giving prescriptions to friends who did not need them – as she knows, because they were selling her their pills.
“He should have known not to give me anything addictive when I already had an addiction problem,” she says. “When I got it, I needed it. But then I should have been supervised more, or questioned about it more.
“If that had happened, maybe I wouldn’t have gotten so bad.”
Anna Mehler Paperny is a reporter for The Globe and Mail.
Methadone blues: Canada trails other nations on treatments for painkiller addicts
In Clement Sun’s methadone clinic in Toronto’s east end, patients – an elderly couple, a tattooed young man, a woman in her 30s – flip through magazines and sit on folding chairs in the bright light sifting in from windows facing Danforth Avenue.
The vast majority of the people who come to Dr. Sun’s clinic for treatment, providing urine samples in a washroom equipped with four surveillance cameras to minimize cheating, are there because of prescription drugs their doctors gave them.
These addicts are filling methadone clinics across the country. Dr. Sun estimates that three times as many Ontarians need addiction treatment for prescription drugs as are now getting it. And only about half the province’s methadone clinics offer comprehensive counselling about what patients are getting into.
The highly addictive, heavily policed substance, while ideal for relatively hard-core addicts, has been criticized as too blunt a treatment for complicated prescription-drug addictions.
“If the only tool you’ve got in the box, essentially, is methadone, we may be consigning individuals with relatively short histories of drug use to far longer periods of maintenance with drugs that could be far more difficult [to quit],” says Doug Gourlay, an anesthetist at Toronto’s Centre for Addiction and Mental Health and Wasser Pain Management Centre.
Canada, in fact, is one of the few developed countries in the world not funding the most common alternative: Buprenorphine – the method of choice for treating prescription-drug addictions in the United States and much of Europe – is almost identical to methadone in function, but less addictive and less likely to cause an overdose.
However, it’s also far more expensive than methadone; while most provinces have approved its use, they don’t cover it because of the price.
If it were widely available, Dr. Sun says, more patients would get treatment: Buprenorphine doesn’t require as much supervision, so patients who don’t live close to specialized clinics could still get access to it.
“We’re in the embarrassing situation of being probably the last developed country to have buprenorphine available,” Dr. Gourlay said, “and now we’re not making it easily available to those who would most benefit.”
Anna Mehler Paperny