Painkiller deaths double in Ontario

Tuesday, December 8, 2009 – Globe and Mail

Painkillers are causing twice the number of overdose deaths they were two decades ago, a new study has revealed. And most of those who died obtained the medications through a doctor’s prescription and had seen a physician within the last month of their life.

The increase mirrors a dramatic rise in prescriptions for oxycodone. The potent opiate, found in OxyContin and Percocet, has proliferated in an epidemic of chronic pain turning Canadians into a nation of pill-poppers – using more prescription opioids per capita than any country but the United States and Belgium.

It’s an indication that many doctors have underestimated the power and complexity of prescription opioids, and their ability to harm as well as help, said Irfan Dhalla, a doctor at St. Michael’s Hospital in Toronto and the report’s primary author.

Dr. Dhalla is one of many physicians and researchers who argue that prescribing physicians – from general practitioners to gynecologists – need to reconsider the treatment of patients suffering from chronic pain and addiction.

“Physicians will be very surprised to learn just how many deaths occur from prescription opioids each year,” Dr. Dhalla said.

This new information comes as the Ontario government changes the way it regulates prescription opioids – placing limits on how many pills it will pay for per prescription, and possibly adding more addiction-treatment options for patients. Helen Stevenson, head of the province’s public drug program, says this urgent action is necessary because of a slew of evidence about Ontarians becoming hooked on these drugs.

One case brought to light by the study involved a patient who “walked out of the pharmacy with more than 2,000 pills” – all obtained through an apparently legitimate prescription.

“That, in itself, shocked us,” Ms. Stevenson said. “When we then saw this bigger picture of our data, we realized the urgency of starting to implement measures.

The study, published today in the Canadian Medical Association Journal, found that between 1991 and 2007, opioid-related deaths doubled in Ontario – to 27.2 per million people from 13.7 per million. During that period, prescriptions of oxycodone – added in 2000 to the list of drugs Ontario’s drug plan covers – shot up 850 per cent, and the number of oxycodone-related deaths quintupled.

More tellingly, about two-thirds of people dying of prescription opioid overdoses had seen a doctor in the preceding month; more than half had filled an opioid prescription in that time. The typical patient had seen a doctor 15 times in the year before he or she died.

Those overdosing on oxycodone are predominantly people with family doctors or, at the very least, easy access to a walk-in clinic. They aren’t buying their drugs on the street – or, if they are, it’s to supplement prescriptions.

Although there have been studies of opioid-related deaths in the United States and elsewhere, this is the first study examining trends in prescription-opioid deaths in Canada – and the first in the world to examine whether people dying of prescription-opioid overdoses are within the health system.

“If people are seeing physicians and getting prescriptions and going to pharmacies, that would certainly suggest a missed opportunity for prevention,” Dr. Dhalla said. “If you’re seeing your doctor 15 times in the year before you die, that means there are 15 visits where the fact that a person might be on multiple drugs that interact with each other could be addressed, psychological problems could be addressed, alternative strategies for dealing with chronic pain could be considered”

The study found prescription opioids kill, on average, 300 people in Ontario each year. HIV/AIDS kills 100 people annually; H1N1 has killed 100 people in Ontario so far. Other illicit drugs cause few overdose deaths by comparison.

“The perception, if you watch the movies, is that people inject heroin and die,” Dr. Dhalla said. “In Ontario there are far more deaths from prescription opioids than heroin. Deaths from illicit drug use without prescription opioids are relatively rare.”

It’s a case of a potent drug – as much as twice as powerful as morphine, which is far less easily available – not getting “the respect it deserves,” says David Juurlink, a doctor at Sunnybrook Health Sciences in Toronto and one of the report’s authors.

“It’s a very, very common medication, and familiarity breeds contempt,” he said.

A set of guidelines on opioid prescriptions, pain and addiction treatment drawn up by a team of experts from across the country is in the final stages of feedback, and will be released early next year.

Before the end of the month, Ontario plans to impose limits on the number of opioid pills it will cover, per prescription. And in January, the province will decide whether to fund buprenorphine – a less-addictive alternative to methadone that costs more per pill but would make addiction treatment available to more people.

“We don’t really have the authority to dictate what a doctor can prescribe,” Ms. Stevenson said. “Where we have the authority is around what we’re prepared to pay for.”

But while addiction doctors say it’s high time to add buprenorphine to the provincial formulary, they’re worried that limiting access to drugs is too blunt a tool, and will deprive patients suffering from pain of the treatment they may need.

“[Limits] might also actually reduce the availability of oxycodone and other prescribed opioids for patients who legitimately benefit from it,” said Curtis Handford, a doctor at the Centre for Addiction and Mental Health in Toronto. “Physicians still need to be able to access medications if they feel they’re warranted.”

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