OxyContin, a powerful painkiller, disappeared from Canada on March 1. It was replaced by OxyNEO, a chemically identical, but tamper-resistant version. The anger, confusion and physical pain that has resulted from this seemingly benign upgrade speaks volumes about what's wrong with our approach to drugs in this country.
We pay far too little attention to the effectiveness of medications used for legitimate purposes like pain control. At the same time, we fret incessantly about drug abuse while doing virtually nothing to prevent or treat addiction. Worse yet, we behave as if these challenges are somehow unrelated when, in fact, they are intricately linked.
The OxyContin story is a prime example of this public-policy hash and underscores the crying need for a plan, a strategy. We need a War on Pain a lot more than we need a War on Drugs.
Getting rid of OxyContin – a drug that can be crushed by addicts who want to snort or inject it rather than use it for its intended purpose, to relieve severe pain – is a good thing, at least superficially.
Concomitant with the disappearance of OxyContin, however, a number of provincial and federal drug plans have "de-listed" OxyNEO – meaning it is no longer paid for by public drug plans. While most patients already prescribed OxyContin will be able to get OxyNEO and have it paid for by the drug plan for a transitional period of up to a year, it will be very difficult for new patients to get the drug, other than those being treated for cancer or requiring it for palliative care.
This too is a good thing, at least theoretically.
Annual prescriptions for oxycodone (the generic name for OxyContin/OxyNEO) have soared nearly 80-fold since the drug was introduced in 2000. Far too many people are taking this highly addictive drug for far too long, especially since there is no research showing that long-term use is safe or effective.
Governments hope the new rules will slow the soaring number of oxycodone prescriptions – 1.6 million last year alone – and reduce drug plan costs, which exceed $150-million annually.
So why so much angst over a seemingly sensible change in public policy?
Two reasons: 1) Because the OxyContin decision will have a ripple effect, one that could have many unintended negative consequences; and 2) The decision, while well-intentioned, seems to ignore the harsh reality that chronic pain and addiction are sprawling societal problems that extend far beyond access – legitimate or otherwise – to a single drug.
Let's start with the immediate consequences. There are an estimated 200,000 prescription drug addicts in Canada. (More than there are addicts hooked on illicit drugs, by the way. And the distinction is also an artificial one: Oxycodone is only a couple of molecules removed from heroin.) For many, OxyContin – known as hillbilly heroin – is the fix of choice.
With the new rules, one of two things will happen to Oxy addicts: Without access to OxyContin, they will suffer severe withdrawal, or they will switch to another form of opioids like hydromorphone (brand name Dilaudid) or heroin.
There are fewer than 100 "detoxification" beds (for those suffering withdrawal) in Canada; the waits for treatment stretch to six months and beyond. There are treatment programs that offer methadone and suboxone, but those too are in short supply.
There have been dire warnings of mass withdrawal in some first nations where OxyContin addiction is at epidemic levels, but this is unlikely. Far more likely is that new drugs will fill the void, and they will be even more costly. (The pharmacy price for OxyContin was between $1.25 and $6 a pill, depending on dosage; on the street, prices ranged from $5 to $80 a pill.) Bottom line: Those who want help kicking their opioids addiction will have little chance of getting it, and those who remain addicted will have an even more costly, desperate addiction.
But street users of OxyContin are just one part of the issue.
An estimated six million to seven million Canadians suffer from serious chronic pain. In the past decade, they have been treated increasingly with opioids, OxyContin in particular. That's because it's a slow-release drug that the maker, Purdue Pharma Canada, cleverly marketed as being less addictive. (Purdue's parent company was fined more than $600-million for these misleading claims. The drug brings in $3.1-billion a year worldwide, so the fines weren't too burdensome.) One of the principal reasons painkillers are overprescribed is that physicians get little formal training in dealing with pain; they tend to get their information from drug reps. Moreover, alternatives to drugs like physiotherapy and psychological counselling are not funded.
And while governments are cracking down on prescribing of OxyContin's substitute, OxyNEO, they are not extending those measures to other opioids.
Without better physician education and improved prescribing guidelines, it is unlikely opioid use will be reduced.
Rather, patients will be switched to other drugs, like Dilaudid, which are just as addictive and far more powerful. These "conversions" are difficult for physicians and patients alike; the Ontario Pharmacists' Association has warned its members that "unintentional dose escalation" is a serious concern. For many patients, the risk of overdose is very real – and one death has already been linked to conversion. (Opioids depress the central nervous system, meaning people can stop breathing if the dose is too high. OxyContin alone kills an estimated 1,000 people a year in Canada.)
This double whammy – the fear of being cut off painkillers and the risk of alternatives being even more dangerous than OxyContin – is concerning. It is certainly not what policymakers had in mind.
"We cannot let people with serious pain become collateral damage of the war on prescription drug abuse," the Canadian Pain Society said in a statement.
But the reality is that people with chronic pain are already collateral damage. Frequently their physical pain is treated – often ineffectually – and the price is steep: addiction. In addition to their injuries and illnesses, those with chronic pain have been victims of aggressive marketing by Big Pharma, lack of investment in rehabilitation, inadequate research in pain control and short-sighted public policy.
It's time for some relief from the suffering, and that will require concerted action.
On April 24, in Ottawa, the first ever Canadian Pain Summit will be held. For more information go to www.canadianpainsummit2012.ca
Editor's Note: Oxycodone is the generic name for the drugs OxyContin and OxyNEO. An incorrect spelling appeared in an earlier version of this article, which has been corrected.