November 9, 2014 – Anna Mehler Paperny, Global News

Ontario’s opioid epidemic is more deadly than ever, new numbers obtained by Global News indicate. And the province hasn’t shifted its tactics to deal with the evolving health crisis killing more than 500 Ontarians a year.

Preliminary 2013 coroners’ data indicate the number of Ontarians killed by prescription opioids continues to rise.

And it isn’t the usual suspects: While oxycodone, the active ingredient in OxyContin and its successor OxyNEO, is being prescribed less often and playing a role in fewer deaths, other drugs have more than made up the difference.

Hydromorph Contin is also made by Purdue Pharmaceuticals. It’s even more powerful, per milligram, than OxyContin; it’s just as addictive.

And, in Ontario, it’s far easier to get.

Meanwhile, the province is beginning to act on the prescription database it created in 2012. But police referrals from a working group parsing those numbers are a drop in the bucket; and prescriptions for these potent painkillers have continued to rise since the working group’s creation last fall, numbers first reported by Global News show.

As Global News reported previously, prescriptions for Hydromorph Contin have been skyrocketing as it replaces prescriptions for relatively restricted OxyNEO.

Hydromorphone, the active ingredient in Hydromorph Contin, has almost doubled as a cause of death in the past two years. Methadone and morphine-related deaths have increased, as well, even as oxycodone, once the dominant cause of opioid-related deaths, continues to drop.

Interestingly, heroin is also causing more deaths – possibly as people who started on prescription opioids turn to a relatively cheaper street drug.

This is translating to changes in these drugs being sold on the streets, says OPP Constable Chris Auger, with the Drug Enforcement Unit.

“We do see a switch to other opioids,” he said – Fentanyl and Hydromorphone among them.

Opioid-related deaths 2002-2013

Graphic by Anna Mehler Paperny; data from Ontario Coroner

Note: Where a death involves more than one opioid, it may appear twice in the chart above. Preliminary coroner’s numbers indicate 477 people in Ontario were killed by opioids in 2013, and an additional 110 were killed by a combination of opioids and alcohol.

The number of deaths involving both opioids and alcohol is also increasing for certain drugs, preliminary coroner’s numbers show:

Data from Ontario Coroner.

When Purdue phased out OxyContin and replaced it with “tamper-resistant” OxyNEO, Ontario was among many provinces to restrict its coverage for the new drug.

Health Minister Eric Hoskins cited that step the last time Global News asked him about skyrocketing opioid prescriptions, which have shown the province’s strategy has worked, but only in the narrowest sense – there’s less Oxy out there, but more of everything else.

When Global News asked in July about the increasing number of opioid prescriptions, Hoskins said that while Ontario was “always looking to improve” its strategy it had no immediate plans to crack down on prescription opioids.

Hoskins was not available for an interview for this article. An emailed statement cited the 2012 OxyNEO restrictions and narcotics monitoring system.

That monitoring is starting to bear fruit: In the past year, the province’s Narcotics Monitoring Working Group has referred

• nine cases of “possible double-doctoring” to the Ontario Provincial Police;
• 16 cases of “potential inappropriate prescribing practices” to Ontario’s College of Physicians and Surgeons;
• and 10 dispensing-related concerns to the Ontario College of Pharmacists.

The cases referred to the OPP are on the “extreme” end of the double-doctoring scale, says the OPP’s Auger – “people that see multiple physicians; not just two.” These nine also comprise a small minority of the double-doctoring or prescription drug diversion cases the OPP deals with every year.

“We are working with the Ministry of Health and we have a great relationship [with] them, working back and forth on these cases. And it’s been very effective that way,” he said.

“A referral, to us, it’s a starting point.”

(There’s been no disciplinary action yet taken against any of the pharmacists referred, their College says. Global News is manually combing through dozens of disciplinary actions against physicians, which are searchable by name but not year or offence.)

READ MORE: Hooked – Canada’s pill problem

Despite all the public health warnings regarding giving out strong, long-acting opioids for chronic, non-cancer pain, it’s clear Canadian physicians are still providing these prescriptions?

Why?

For many of them, it’s what they’ve been taught.

No one wants to see a patient in pain.

And it’s often easier to write a prescription for powerful pills than to sit down with a patient and go over other, effective but often more complicated options, such as physiotherapy or other interventions, pharmaceutical or otherwise.

“It takes about 20 seconds to write a prescription – and 30 minutes not to write a prescription,” said David Juurlink, an internist at Sunnybrook Health Sciences Centre who specializes in drug safety.

That said, “opioids are a very heavy, blunt instrument.” The clinical-trial evidence behind their use as long-term painkillers is scant, critics say. And there are better ways to treat pain.

But the solutions to this tidal wave of prescriptions aren’t easy: Putting a hard cap on dose amounts ignores that some people genuinely do need these drugs.

Doctors and advocates for pain-sufferers balk at the idea of only allowing specially trained physicians to prescribe opioids, the way only specially trained doctors are allowed to prescribe the methadone used to treat opioid addictions.

And putting all opioids under Ontario’s Exceptional Access Program, which involves more paperwork and more scrutiny for drugs not meant for routine prescribing – and which OxyNEO’s now on – could overwhelm that system, Juurlink says.

“The Exceptional Access Program does not have the capacity to accommodate those kinds of requests.”

READ MORE: Pilfered Canadian pills are fuelling a U.S. health crisis

Ultimately, Juurlink argues, a solution must go much further than Ontario’s one-drug crackdown.

“The idea that the one intervention and no longer paying for one particular product … is going to make a huge dent in the big picture is not really believable,” he said.

“If we wanted to make a really big dent in opioid-related deaths we would find a way to get doctors to prescribe much, much, much less readily.”