Deaths from prescription opioids have increased in Ontario over the past two decades as opioids have become more commonly used to treat pain.

The Ontario government has introduced legislation to better monitor opioid prescriptions and to educate doctors and the public about the danger of opioids.

The only unusual thing about the death of Heath Ledger, the Oscar-nominated star of Brokeback Mountain and the Dark Knight, was his fame. Like thousands of other North Americans each year, Ledger died from a prescription drug overdose. His death was ruled an accident, and the autopsy that followed his death in 2008 found several prescription drugs in his bloodstream. The two that probably played the most important role were oxycodone, the active ingredient in OxyContin, and hydrocodone, a similar but less potent narcotic.

Several hundred deaths related to this class of medications—opioids—occur each year in Ontario. The annual number of deaths related to opioids is more than double that from HIV infection.

As with cocaine and heroin, most deaths are accidental and occur in young people. But in contrast to cocaine and heroin, it is the health care system that is responsible for distributing prescription opioids like OxyContin.

Doctors prescribe opioids for patients who are suffering from pain. While many patients do benefit from these medications, others become addicted, and some accidentally overdose. Other patients sell their drugs to people who simply want a high.

For these reasons, the Ontario government passed the Narcotics Safety and Awareness Act last year. The government hopes that the new law will reduce the rates of addiction and death.

But how did we get in this situation in the first place? And what should we do to reduce opioid addiction and overdose, while still making sure that people who will benefit from receiving opioids have access to this class of medications?

How We Got Here

For most of the 20th century, physicians shied away from using drugs like morphine because of the risk of addiction and overdose. Many patients with terminal cancer suffered unnecessarily as a result. Today, virtually no one needs to suffer from excruciating pain as death approaches. Because opioids are so effective in treating pain, they have become one of the most widely used classes of medications in palliative medicine. They are also very useful to treat acute pain, from a kidney stone or after an operation, for example.

About 20 years ago, a small number of pain physicians started to promote the use of opioids for chronic pain that is not related to cancer—back pain or knee pain, for example. Doctors want to ease suffering, and prescribing opioids seemed to be a good way to do that.

But because pain is subjective and experienced only by the patient, and because the risks are unpredictable, it is very difficult for a doctor to know whether prescribing opioids to a particular patient is the right thing to do. And if the opioids don’t work, then what? Many doctors feel obliged to increase the dose. Although this strategy sometimes works in the short-term, the long-term effects of high-dose opioids have been poorly studied.

With very little evidence to guide practice, pharmaceutical companies stepped into the arena and aggressively promoted products like OxyContin. In fact, the company that marketed OxyContin went too far, and was eventually punished with a $630 million fine in the United States for illegally marketing the drug.

What Ontario is Doing Now

Through its new narcotics strategy and the Narcotics Safety and Awareness Act, the Ontario government is focused on more closely monitoring the prescribing and dispensing of opioids and other monitored drugs. The Act provides the government with the ability to collect data on prescribing and dispensing practices. The narcotics strategy also proposes to produce a database to monitor opioid prescriptions, provide better education to doctors, pharmacists and the public, and facilitate better access to addiction treatment. The database will allow for the central monitoring of prescribing behaviors and patterns, and can support the identification of individuals or groups for education or programs around opioid prescribing.  However, the details of exactly when this database will be up and running are not clear.

What Others are Saying and Doing

Some critics wonder whether Ontario’s new strategy will curtail access to pain medications and start us on a road back to the 1940s, when doctors wouldn’t prescribe opioids even to patients with terminal cancer.

Some pain specialists believe that pain is already an underserviced domain in medicine, and that doctors are being scared away from prescribing opioids, therefore depriving patients of important pain relieving medications.

Others wonder whether the government is doing enough.

In Canada, Manitoba has moved most aggressively on this issue. In March of last year, the government introduced a policy requiring doctors to obtain permission before they can prescribe certain opioids. In Saskatchewan, the College of Physicians and Surgeons monitors drug prescriptions using provincial data and investigates unusual prescribing by physicians, advising physicians directly on inappropriate use of prescription opioids. In the United States, the state of Washington is mulling over the idea of forcing doctors to register and undertake additional education if they want to prescribe opioids on a long-term basis to patients who don’t have cancer.

Some people, like the group behind, have even suggested that specific opioids be removed from the market. Although this would be a drastic step, advocates of this approach argue that complete removal may be the only way to redress the harms caused by inappropriate marketing.

Ada Guidice Thompson, whose son Michael died in 2004 from an opioid overdose, stresses that the stigma attached to drug addiction is extended to those with opioid addiction, influencing public perceptions and policies. “They don’t become addicted overnight, it’s a gradual process. Many of these individuals are patients under the care of a physician who receive a legitimate prescription, for a narcotic, for pain.”

To watch a CBC news feature on prescription opioid use in Ontario, click here.

Do you think Ontario's narcotic strategy is on the right track?

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