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This is the last in a four-part series for rabble.ca. To read the previous article, please click here.
"Everybody along the way is making money and we're killing people."
Heroin? Cocaine? Tobacco?
No, that's how Detective Constable Tom Fournier of the Brockville Police sums up the impact of doctors prescribing large amounts of prescription narcotics for chronic pain in Ontario.
Almost every day, one Ontario resident dies from an overdose of a prescription narcotic. The number of such deaths increased by more than 60 per cent between 2002 and 2008; since then, the annual total has plateaued, but not decreased.
That's according to official statistics that Dr. Andrew McCallum, the chief coroner of Ontario, presented to the province's first coroner's inquest into prescription painkiller deaths.
And for every person who dies -- the majority from overdoses that are accidental -- many more end up struggling with problems of addiction, Dr. Meldon Kahan, an addiction expert at Sr. Joseph's Health Centre in Toronto, told the inquest.
The "everybody" who benefits from the surge in prescribing includes, Fourner said in an interview, the pharmaceutical companies that market the drugs, doctors who prescribe them, pharmacies that dispense them, and patients who sell their prescription drugs to others.
It took a formal written complaint from the police (Fournier) to get the College of Physicians and Surgeons of Ontario (CPSO) to investigate the narcotic prescribing habits of local doctor Alan Redekopp.
"We were concerned about the availability of OxyContin on the streets of Brockville," Fourner explained.
But Fournier also pushed hard for a coroner's inquest -- the first such Ontario inquest to look into prescription painkiller deaths. (It began June 2 and, after 17 days of testimony from 49 witnesses, concluded June 29th.)
The lack of public attention to the issue of prescription painkiller misuse, abuse and deaths is clearly frustrating for Fournier -- and he isn't alone.
The death toll: similar to driving deaths
In 2006, there were the "same number of deaths" from prescription opioid intoxication as the number of drivers who died in Ontario that year in motor vehicle accidents, Ontario's deputy coroner Dr. Bert Lauwers told the inquest.
"Think about the amount of [public policy] energy that has gone into safe driving practices with regard to seatbelts" and drunk driving, he told the inquest.
"Now I suggest to you that until recently there's been very little about the issues of opioid intoxication" and the data that arise from it, Lauwers testified. "And they are all accidental deaths . . . well not all, but the vast majority of opioid related deaths are accidental deaths."
The inquest was called to examine circumstances around the 2008 deaths of two Brockville residents -- Donna Bertrand, a 41-year-old patient of Redekopp's who was prescribed high doses of OxyContin for a sore back, and Dustin King, a young man who died from oxycodone toxicity in Bertrand's apartment.
But importantly, the inquest was also convened to consider the scope of the problem in Ontario -- the "prescribing, diversion and monitoring of opiates" in Canada's most populous province.
The drug that accounts for the largest proportion of prescription narcotic deaths in Ontario -- 148 out of the total 327 in 2008 -- is oxycodone, according to figures from the coroner's office. (Oxcodone toxicity deaths increased from 35 in 2002 -- a more than 300 per cent increase.)
Chief coroner McCallum testified that the "narrative" around the 148 deaths revealed that in the vast majority of cases the deceased had taken long-acting OxyContin. (Post mortem toxicological analysis cannot identify the source of the active ingredient oxycodone or how it was ingested.)
Some of those who died were using OxyContin that was not prescribed for them, but "some -- and this is an important consideration, were using it within the context of therapy," he told the inquest.
The official death toll from prescription narcotics is undoubtedly higher than the official coroner's numbers, the inquest was told.
Dr. Irfan Dhalla, who practices medicine at St. Michael's Hospital in Toronto and has published many research papers on prescription opioids, noted that not all narcotic toxicity deaths are investigated by the coroner's office.
McCallum testified that oxycodone toxicity deaths rose "exponentially" after 2000. That's the year OxyContin, manufactured by Purdue Pharma, became available through Ontario's drug benefit plan. The plan provides pharmaceutical drugs for about 25 per cent of the population, mainly social assistance recipients and senior citizens.
McCallum attributed the overall rise in prescribing to a change in the opioid prescribing philosophy from an "as-needed" basis to slow release dosing, which he said is clearly beneficial for patients after surgery but "has spilled over" into prescribing for chronic pain. (The use of long acting oxycodone is also not controversial for cancer patients and for end-of-life care.)
Pharma's marketing campaign
According to addiction expert Kahan, the change in physician's prescribing practices "can be attributed largely to an expensive and sophisticated marketing campaign by the pharmaceutical industry."
The campaign promoted a few simple -- but false -- messages such as that "addiction is extremely rare in chronic pain patients, controlled release opioids are less addictive than immediate release opioids, and there is no ceiling dose for opioids," he said in a statement filed as an exhibit.
In the United States in 2007, the manufacturer of OxyContin was fined $634-million for making false claims about the drug's risk of addiction. Purdue Pharma has not faced similar charges in Canada.
All prescription narcotics are potentially addicting, Kahan told the inquest.
However, Oxycontin "may be particularly addicting, in the sense that it has an immediate release component to it where about 1/3 of the dose is released quickly, which gives patients a greater psychoactive effect than with other strictly controlled release opiates," he stated.
And OxyContin "comes in these very large, very high strength tablets of 80 mgs and 40 mgs and we know that euphoric, or reinforcing effects are related to the dose," Kahan told the inquest.
The 80 mg and 40 mgs tablets are being widely prescribed to patients, but are also finding their way onto the street and are being sold to people who have become addicted.
Several police officers told the inquest that increasing amounts of oxycodone-based tablets (mostly Oxycontin) are being found along with illegal drugs when police execute warrants for seizures.
Supply leads to street price drop
For example, in Cornwall, Ontario, 2,108 tablets with a street value of $49,000 were seized during raids in 2009, up from 250 tablets just the year before, Detective Sergeant Shawn White of that city's criminal investigation unit told the inquest.
The street price for an 80 mg OxyContin tablet has recently dropped to $50, from $80 in 2008, because supply is more available, he testified. "The biggest source still comes from doctors either over-prescribing or not prescribing responsibly."
In a two-year period between 2008 and 2010, eight deaths in Cornwall -- a city of 50,000 - were linked to prescription drug misuse, and the deceased ranged in age from 18 to 58 years of age, White said.
Undercover Ontario Provincial Police drug operations that involved the seizure of Oxycontin tablets numbered 120 in March 2011, up from 30 in March 2009, Detective Sergeant Rick Hawley of the Ontario Provincial Police told the inquest.
Because prescription painkillers are legal, addressing their misappropriation and misuse is challenging, Hawley stated. The situation is so serious that the province should create a special joint police task force, he said.
Several witnesses told the inquest that it was crucial to educate doctors and change their prescribing habits since so many physicians continue to prescribe high doses of prescription narcotics for chronic pain.
High doses for people on social assistance
In 2008, almost one-third of those under 65 years of age who were on the Ontario drug benefit program and being prescribed OxyContin were receiving prescriptions for more than the 120-135 mgs a day that is now considered a "watchful" or threshold dose for the drug, Dhalla told the inquest.
The amount of a watchful dose was recommended in the 2010 Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain, and that guideline is a good first step, he stated.
But the evidence about the use of prescription opioids for chronic non-cancer pain is weak, so it's particularly important that members of an advisory panel who are helping to draw up a guideline should be free of conflicts of interest, he said.
In other jurisdictions that are trying to come to grips with prescribing problems, such as Washington state in the United States, the level of a watchful dose has been set lower than in the Canadian guideline, Dhalla stated.
About one-third of the members of the National Advisory Panel for the 2010 Guideline stated that they had previously received support of some type from Purdue Pharma, Dhalla told the inquest.
Part A of the Guideline itself states that it is "constrained by the paucity of evidence to support most of the topics where recommendations for practice were considered necessary and relevant. This required a heavy reliance on the opinion and expertise of the National Advisory Panel to develop recommendations."
Meanwhile, Cornwall has set up its own OxyContin Task Force, White told the inquest.
The task force aims to educate doctors to find alternate ways of managing patients' pain instead of prescribing opioids, help those who are already addicted to get into treatment programs and, through policing, limit demand on the street.
Meanwhile, some people profit and others die.
The jury is due to deliver recommendations on Monday afternoon. Rabble.ca will run them.
Ann Silversides has a Canadian Institutes for Health journalism award to research issues related to prescription painkillers.
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