A wave of new prescription painkillers presents a potential danger to society, some medical researchers warn.“The deaths are going to continue,” said Dr. David Juurlink, a leading Canadian researcher on pain medication. “The only thing that’s going to stop them is reduced prescribing.
“Pharmaceutical companies have made billions and billions of dollars. And over the last 20 years, more than 100,000 people have died in North America, and probably many millions of people have become addicted to these drugs. And anyone who says otherwise is not being honest.”Linda Barkhouse, a registered nurse since 1990 and a pain-management consultant since 1993 with Encompass Health Systems, believes that battling chronic pain through long-term use of medication is a fiction, perpetrated by an industry and physicians who make millions from it.“I’ve never, ever seen it as bad as this in my career,” Barkhouse said of painkiller addictions. “This has become an epidemic. It is destroying lives and destroying society.”
With an aging population, a brewing controversy surrounds the increasing number of painkillers hitting pharmacies in 2012, given the associated risk of addiction — and even death.
A collection of medical journals have highlighted the growing problem, and the U.S. Centers for Disease Control released a report last month calling the number of opioid-related deaths at “epidemic levels,” noting that more people now die from opiates than from heroin and cocaine combined. According to the CDC, the opioid death toll has almost eclipsed that of car crashes in the U.S. Yet, Health Canada has not raised many alarm bells on the issue. In fact, the most recent statistics provided by Health Canada suggest use of psychoactive pharmaceutical drugs — which include pain relievers, stimulants and sedatives — have remained roughly the same the last few years.
The Canadian Alcohol and Drug Use Monitoring Survey, Health Canada’s annual check up on alcohol and illicit drugs use, says that in 2010, 26 per cent of respondents reported psychoactive pharmaceutical use. But only one per cent reported using psychoactive pharmaceutical drugs for the feeling or to get high. Critics say the Health Canada poll flies in the face of anecdotal evidence, sidesteps the issue of rising rates of prescriptions, and suggests a lower rate of abuse than for, say, gambling. According to IMS Brogan, a unit of IMS, a global health-information company, sales of painkillers in Canada in 2010 was $2.5 billion, an almost 60 per cent increase from 2006, when sales were $1.6 billion.
“Many of these reports are based on estimates of opioid pain reliever production, importation and exportation and not on actual consumption by Canadians,” Health Canada spokesman Gary Holub wrote in an email to the Star. “The increases identified in these reports do not necessarily reflect an increase in use or abuse of these types of pain relievers. Rather, they provide information on the supply of the pharmaceutical in the legal market place.
“It is important to note that the increases described in some of the research reflect changes since the late 1990s and may be due to a number of influencing factors, including changes in prescribing patterns, availability of these products in the market place, and an aging population.”
In fact, the CADUMS survey suggests that Canadians abusing prescription painkillers, stimulants and sedatives is so low that in most categories by age group or sex Health Canada provides no number, listing it as statistically insignificant. CADUMS was launched in 2008 and does not provide earlier drug information. Prior to that, Holub said, questionnaires such as the Canadian Addiction Survey in 2004 did not ask about the use of psychoactive pharmaceuticals.
“For some reason, Health Canada and the powers that be have not given this particular public-health emergency the attention that it’s due,” said Juurlink, head of clinical pharmacology and toxicology at Sunnybrook Health Sciences Centre and an associate professor of medicine at the University of Toronto. “I don’t know how many 9-11s worth of people have to die before governments start acting. “If this were salmonella or E. coli, you can imagine what would happen.” Juurlink, who has co-authored a number of medical journal articles on opioid-related deaths, says doctors and patients alike must be made more aware of the dangers of prolonged use of painkillers for non-cancer related pain. In a 2009 Canadian Medical Association Journal article Juurlink co-authored, research showed that between 1991 and 2007 in Canada opioid prescriptions rose 29 per cent. Opioid-related deaths doubled between 1991 and 2004, to 27.2 per million. Prescriptions of oxycodone increased 850 per cent between 1991 and 2007. And the addition of long-acting oxycodone was associated with a five-fold increase in oxycodone-related deaths. Juurlink said that more recent as-yet-unpublished numbers suggest the trend is continuing.
Since Purdue Pharma — the industry leader in manufacturing analgesics — introduced time-release OxyContin in 1996, a range of opioid and other pain-relievers have popped up. Purdue Pharma pain medications include: Biphentin, BuTrans, Dilaudid, Targin, Uniphyl, Uromax and Zytram. As well, there are larger doses of Hydromorph Contin, considered six times stronger than morphine. This is on top of OxyContin, Oxy IR, codeine and more. As well, other companies such as Pfizer, Lilly and Merck make various pain-reliever and anti-inflammatory medications. Janssen-Orthe manufactures a number of painkillers, including Nucynta CR, Paladin, Tramacet, Ultram, Tridural, Duragesic (a fentanyl patch), and the new Jurnista (long-acting hydromorphone).
Media reports this week indicate drug companies are developing a more powerful version of pure hydrocodone, instead of the current stuff mixed with milder painkillers such as acetaminophen. The new medication is less harsh on the stomach but packs up to 10 times the power of such medication as Vicodin. Zogenix hopes to start marketing its pure-hydrocodone brand Zohydro in 2012. Morphine, once considered a heavy-duty drug for serious pain, is now listed on some pharmaceutical pamphlets for moderate pain.
“Strong prescription pain relieving medicines have an established medical purpose and are a necessary component of pain management for certain patients,” Randy Steffan, vice-president of corporate affairs for Purdue Pharma in Canada, wrote in an email to the Star. “These medicines help make life livable for patients who are suffering from chronic moderate to severe pain.”
How addictive are medications such as OxyContin?
“When prescribed appropriately and according to the product monograph approved by Health Canada, prescription opioid analgesics provide safe and effective long-acting pain relief,” Steffan wrote. “However, the potential for abuse and addiction should always be a consideration when prescribing any opioid. They are controlled drugs and must be taken under a doctor’s supervision and guidance.”
Steffan said more pain-relievers are coming on the market to provide physicians and patients a wider range of treatment options, and because there is “a greater awareness of the need to treat pain” by developing better medicines.
In May 2007, Purdue Pharma pleaded guilty to misleading the public about OxyContin’s risk of addiction. The company agreed to pay $600 million in the United States, while the company’s president and two other top officials agreed to pay a total of $34.5 million. These days, Purdue Pharma acknowledges the addictive nature of narcotic analgesics. Though the company does not suggest reduced prescribing, it has launched several “anti-abuse and diversion initiatives,” such as creating a tighter supply chain, working with law enforcement and producing products that are harder to tamper with. Still, Windsor police have said the fastest rising street drug is oxycodone, best known as OxyContin. One recovering opioid addict, who uses the opiate-blocking agent Suboxone to help him avoid relapse, told the Star he used to deal 80 mg OxyContin tablets for $40 to $50.Purdue Pharma also referred questions to the Canadian Pain Society, an association of pain specialists funded by membership fees, grants and an annual general meeting where organizations and pharmaceutical companies purchase booth space.
Dr. Roman Jovey, a general practitioner of 31 years and a CPS spokesman — also the medical director of the Centres for Pain Management, a network of 10 private clinics — says pain medication has its place. But a panacea has not been found. “There are more pain relievers coming on the market because there isn’t the right one yet,” Jovey said. “We continue to struggle to treat chronic pain. It’s the most underserviced domain in Canada.” Jovey said by extrapolating data from a recently published Pain in America report, he estimates pain causes $50 billion to $60 billion in lost workplace productivity every year in Canada. About 20 per cent of patients see doctors for chronic pain. “Pain medication is not an answer by itself,” Jovey said. “It’s an imperfect solution to a complicated problem.” Jovey trumpets what he calls the three Ps of pain treatment: physical, psychological and pharmacological. “Clearly, the best treatment for a chronic pain condition is interdisciplinary, multi-modal treatment,” Jovey said. “But the problem with that is, it’s not paid for. So you look at what physicians have left. We can prescribe medications. And that’s all that’s funded.” General practitioners typically have very little training in pain, Jovey said, and some have none.“Most patients with chronic pain end up losing their job, losing their benefits. They can’t afford physiotherapy or psychological treatments. So you’re stuck with medication.”Jovey said pain medication must be taken as directed to be safe, and that it can work wonders for acute pain. “Pain is an essential thing to life,” Jovey said. “Acute pain warns us of potential tissue damage and makes you do something to avoid that. But we can’t figure out what purpose chronic pain has.” Worse, Jovey said, chronic pain changes the way nerves function. Like a fire alarm stuck on, he said, the ongoing message causes the body to create new synapses — the physical connection between nerves — and ultimately makes pain worse.
Barkhouse argues that nature provides pain so people adjust their lifestyles, with more exercise or stretching and less taxing activities. She said the people who have taken painkillers the longest have the most pain. Yet more painkillers keep coming. So many drugs, Barkhouse argues, create a puzzle for doctors and patients alike. “It’s not based on sound science anymore, it’s based on who’s got the slickest marketing,” said Barkhouse. “People are confused.” Barkhouse said no agency in Windsor tackles the prescription medication issue, which most people consider only legitimate. But she wonders about a business model in which doctors who prescribe medication for chronic pain have patients who will never miss appointments. “It’s totally out of control,” Barkhouse said. “According to the literature, this should be the main health issue for 2012: pain, substance abuse and overdose.”
Theresa Beale, a 50-something travelling salesperson, first started dealing with chronic pain five years ago leading up to hip-replacement surgery. She has used painkillers many times for back and hip pain, but felt like she was on a treadmill — pain, pills, pain, pills. “I think it’s all our first line of attack, something hurts, you take something for it,” she said. “But I’ve learned I can’t get out of that pain unless I get some physio for it.” Beale uses a number of different methods: physiotherapy, massage, breathing techniques, even acupuncture. Other alternatives include vitamin and laser therapies, though none have as much scientific study behind them as do drugs. She now considers drug-free the best. It may take longer to work than medication but she feels the benefits last longer.“I could barely walk, I could not get in a comfortable position, I couldn’t sleep, I couldn’t sit,” she said of her most recent bout with back pain. “It was excruciating. So I started physio and within 10 days I was fine.
“The difference is amazing.”