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.