An Interdisciplinary Approach
Canada has a drug problem.
In many parts of the country, fatal drug overdoses are higher than deaths caused by motor vehicle accidents. In Ontario, opioid-related deaths increased from 127 in 1991, to 550 in 2010, to over 700 in 2014. Between 2011 and 2014, the nation’s spending on drugs to treat opioid addiction rose by sixty percent.[1]
The recent rise in death rates due to addiction and overdose on prescription opioids across Canada has triggered a sense of urgency in both medical and lay communities. Many have urged the federal government to take control of this public health threat, either by implementing a Canadian national strategy, or more drastically, by declaring a national state of emergency.
Recent media attention suggests that this is a new crisis and that the culprit is the over-prescription of opioid drugs. The reality, as it often goes, is far more complex.
According to the International Narcotics Control Board, Canada has the second highest per capita opioid prescription rate in the world. In 2015, doctors wrote fifty-three opioid prescriptions for every 100 people in Canada. In 2014, Canada’s public drug program spent $180.5 million on prescription opioids.[2]
Opioid dispensing levels correlate strongly with harm, which is quantified by increased rate of addiction, increased ER visits due to opioid overdose, neonatal abstinence syndrome, and premature mortality.
Yet, the issue of prescription opioids is only one side of a bigger social concern. On the one hand, the pharmaceutical industry has an interest in these prescriptions. On the other, patients suffering from acute, chronic, or cancer pain desperately seek pain relief.
In the 1990s, with the popularizing notion of a right to pain relief, drug manufacturers saw an opportunity. Despite the lack of science-based evidence showing that benefits outweigh the risks, many pharmaceutical companies in North America began aggressively marketing opioids as an effective, low-risk, and non-addictive treatments for moderate pain.
In particular, Purdue Pharma used an expanded sales force that targeted primary care physicians, most of whom had inadequate training in pain management, to advertise OxyContin for cancer and noncancer pain.
In 2007, after a US congressional investigation, Purdue pled guilty to criminal charges, admitting that they knowingly misbranded OxyContin as less addictive than other opioids. Despite the lawsuit, Purdue continued to be a key player in Canada’s opioid market. In 2012, following a committee review that included physicians with clinical expertise in addiction, palliative care, and pain management, provinces removed OxyContin from its drug plan. Purdue Pharma subsequently pulled OxyContin from the market and replaced it with OxyNEO, a tamper-resistant alternative that is difficult to crush, snort or inject, even though the crisis has little to do with tampering.
After the vacancy left by OxyContin, other opioids grew in popularity. Fentanyl, a drug 100 times more potent than morphine, gained popularity as a street drug and is responsible for the recent rise in overdose deaths. Hydromorphone is currently the most popular long-acting opioid in Canada, with 1.6 million annual prescriptions.[3]
While opioids have improved the quality of life for millions suffering from acute pain, the risks and adverse effects of long-term opioid therapy for chronic pain were, and remain, unclear.
The current Canadian drug approval process is not blameless. Controversially, there is no regulation in place to study or monitor the long-term effects of a drug.
Driven by profit over public health interests, the regulatory drug approval process has allowed the drug industry to have significant sway through its user-fee contributions. Rather than developing long-term safety monitoring, the industry has used this influence to ensure “an efficient and fast” approval process.
As such, opioids were being prescribed to patient populations for periods of time much longer than the formal clinical trials. Once approved, pharmaceutical companies have no financial interest in conducting studies on the approved drug, and even an interest to avoid them.
Last October, the Ontario government announced its first comprehensive Strategy to Prevent Opioid Addiction and Overdose. Effective January 2017, Ontario will be the first province to stop paying for high-strength formulations of long-acting opioids under the Ontario Drug Benefit Formulary. Specifically, the plan will delist opioids that are equivalent to more than 200 mg of morphine per day.
Although the strategy promises continued access to appropriate pain treatment, no alternative medication or treatment has been proposed to replace these delisted drugs.
If history has taught us anything, it’s that removing high-dose opioids solves nothing. Worse, it further perpetuates the already stigmatized image of a ‘drug user’ to include patients suffering from genuine chronic pain.
While the danger of prescription opioids is undeniable, it is equally alarming that one in five Canadians live with chronic pain, a serious, common, and undertreated medical issue. Even after adjusting for various socio-demographic factors and effects of long-term illness, such as age, ethnicity, and housing, patients with severe chronic pain had a forty-nine percent greater risk of death compared to all other causes of death and a sixty-eight percent higher risk of death compared with all cardiovascular disease related deaths.[4]
Socioeconomic factors are closely correlated with chronic pain. Advocates calling for the right to adequate pain management come from both inside and outside the medical community. These advocates posit that pain, both acute and chronic, is inadequately addressed for a variety of cultural, attitudinal, educational, political, religious, and logistical reasons. Consequently, inadequately-treated pain is linked with a constellation of major physiological, psychological, economic, and social ramifications.
The problem with the current prescription drug crisis is not singular. The solution must be multifaceted to address a nuanced and widespread problem in the healthcare system. It starts with gaining a better understanding of pain and the long-term effects of painkillers, but we also need a tighter drug approval process, a curtailed drug industry, and better education and training for physicians and users alike on pain treatment.
The Trudeau government must take caution against implementing any measures that may further stigmatize an already vulnerable population by unreasonably impeding patients’ right to pain relief, or unnecessarily subjecting them to further suffering. Any effective national strategy must take an interdisciplinary approach to striking a balance between the right to pain treatment and drug abuse.
This article was written by Jia (Kay) Wang, an Arts & Science graduate from McMaster University and a part-time graphic designer. She strongly believes in the value of interdisciplinary thinking and purposeful design in order to create meaningful and sustainable change.
This article is part of the Osgoode Health Law Association’s Perspectives in Health column. Keep up to date with the HLA on Facebook (Osgoode Health Law Association, Osgoode Health Law Association Forum) and Twitter (@OsgoodeHLA).
If you would like to write with the Osgoode HLA, please contact Adrienne Shnier (AdrienneShnier2016@osgoode.yorku.ca).
[1] Tara Gomes, et al, “The burden of premature opioid-related mortality,” Addiction, vol. 109, pp. 1482-88, 2014; Parvaz Madadi, Doris Hildebrandt, Albert Lauwers & Gideon Koren, “Characteristics of opioid-users whose death was related to opioid-toxicity: a population-based study in Ontario, Canada,” PLoS ONE, vol. 8, e60600, 2013[2] Peter McKnight, “Canada’s opioid crisis: We are all enablers”, (August 2016), online: Globe Mail; Karen Howlett, “Ontario to stop paying for high-dose opioids”, (24 July 2016), online: Globe Mail.
[3] Carly Weeks & Karen Howlett, “Number of opioid drug prescriptions in Canada skyrocketing”, (5 April 2016), online: Globe Mail; Prescription Opioid Policy Framework, CAMH (Toronto: CAMH: Centre for Addiction and Mental Health, 2016).
[4] Nicola Torrance, Alison Elliott, Amanda Lee & Blair Smith. Severe chronic pain is associated with increased 10 year mortality. A cohort recod linkage study. Eur J Pain. 2010 (Apr); 14(4): 380-386.