Peter McKnight is an adjunct professor in the School of Criminology at Simon Fraser University.
You're familiar with the popular portrayal of the drug dealer: an evil and insidious grim reaper who visits agony and angst, disease and death upon the community.
But according to a recent series of Globe and Mail articles, the drug dealer has a rather different look: an educated and respectable man or woman in a white coat, a professional healer who doles out dope from the confines of an antiseptic office.
The Globe's investigation found that in 2015, doctors wrote 53 opioid prescriptions for every 100 people in Canada, and with predictable results. Between 2011 and 2014, spending on drugs to treat opioid addiction rose a whopping 60 per cent, although Alberta, which is experiencing an epidemic of opioid addiction, spends far less on treatment than any other province.
In effect, then, doctors have now found themselves in the awkward position of having to prescribe one drug to solve the problem caused by their prescribing another. And the solution seems obvious: Stop prescribing, or overprescribing, the first drug.
A number of medical organizations, including the Michael G. DeGroote National Pain Centre at McMaster University and the College of Physicians and Surgeons of British Columbia, have issued guidelines aimed at encouraging or requiring doctors to do just that.
Among other things, the guidelines stress that doctors should assess patients' psychiatric status and risk for opioid addiction before prescribing opioid painkillers or other commonly abused drugs. Furthermore, the guidelines require physicians to inform patients of the benefits of non-drug therapies for chronic pain.
While such guidelines can help solve the problem of opioid overprescription, this solution highlights more, and more serious, problems. To begin with, while it's essential that physicians assess their patients for risk of addiction, most family doctors, and even most psychiatrists, receive very little training in addiction medicine.
Fortunately, addiction is receiving increasing attention in some provinces: Addiction specialist Dr. Keith Ahamad, of the British Columbia Centre for Excellence in HIV-AIDS, notes, for example, that St. Paul's Hospital in Vancouver is now home to the largest addiction medicine fellowship in North America.
Yet medical students are still not required to complete a rotation in addiction medicine, which means you can graduate from medical school knowing next to nothing about addiction. Dr. Ahamad and his colleagues are working to change that, but if doctors don't know anything about addiction, they might not know when their patients have a problem, let alone what to do about it.
That said, the problem is much bigger than doctors. It's not as though physicians suddenly decided, against all medical wisdom, to hand out drugs like Tic Tacs. Rather, they have been taught to do so. They have been encouraged to do so. And they have been rewarded for doing so.
Sure, we like to tell ourselves that we're an anti-drug society, as we celebrate every draconian law imposed to crack down on illicit drug dealers. But then we run to our doctors and demand a pill for whatever ails us. And we run to the government and demand that it pay for it.
The government responds by funding drug therapy, but not non-pharmaceutical treatments, like cognitive-behavioural therapy, that might make a significant difference in the lives of people suffering from chronic pain. And provincial medical plans reward doctors financially for seeing a lot of patients for short periods of time, which all but precludes the possibility of their doing anything other than writing another prescription.
Opioid overprescription is, therefore, a societal problem, much like addiction itself. And it will require a societal solution. Any effort to solve the problem is certain to fail unless we engage in a thorough rethinking of our approach to prescription drugs, rather than simply relying on doctors to provide a remedy. After all, if doctors are the dealers, then we are the enablers.