Painkillers are causing twice the number of overdose deaths in Ontario than they were two decades ago, a precedent-setting study has found. Most of the people these opioid-related drugs are killing got them through a prescription and had seen a doctor in the month before they died.
The increase mirrors a dramatic rise in prescriptions for oxycodone, a potent opiate found in OxyContin and Percocet that has proliferated in an epidemic of chronic pain that has turned Canadians into a nation of pill-poppers - using more prescription opioids per capita than any country but the United States and Belgium.
It's a stark sign of how much doctors have underestimated the power and complexity of prescription painkillers and their ability to harm as well as help.
"I think physicians will be very surprised to learn just how many deaths occur from prescription opioids each year," said Irfan Dhalla, a doctor at St. Michael's hospital in Toronto and the report's primary author.
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 shocking slew of the evidence of Ontarians becoming hooked on these drugs.
One person in the data the provincial panel examined "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 Canadian Medical Association study, released Monday, found that between 1991 and 2007, opioid-related deaths doubled in Ontario - from 13.7 per million people to 27.2. During that same period, oxycodone prescriptions - 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 who died of prescription opioid overdoses had seen a doctor in the past month; more than half had filled an opioid prescription in that month, and more than 80 per cent in the previous year. The typical patient had seen a doctor 15 times in the year before they 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 they're obtaining with some degree of legitimacy.
Although there have been studies of opioid-related deaths in the United States and elsewhere, this is the first study of its kind 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 were seeing your doctor 15 times in the year before you died, that means there are 15 visits where the fact that a person was on multiple drugs … 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, by comparison, 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 hospital 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 teams 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 - an 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. … 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 limiting access to drugs is too blunt a tool, and will deprive patients suffering legitimate 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, an addictions doctor at the Centre for Addiction and Mental Health. "Physicians still need to be able to access medications if they feel they're warranted."