Prescription opioids, a small Ontario community, and the failure of the war on drugs
At the intersection of London Road and Victoria Street, otherwise known as Highway 2 and Highway 21, lies Thamesville, Ontario, population 928. This tiny burg is part of the sprawling municipality of Chatham-Kent, about an hour from the Windsor-Detroit border. There are few people on the streets, and only a handful of businesses: a Mac’s convenience mart, a small consignment store, the Schmid Jewellery and Gift Shop, and the John C. Badder Funeral Home. Thamesville shares its name with the nearby Thames River, a placid waterway that continues southwest, cutting a line through the middle of Chatham-Kent. A network of small places with a combined population of about 104,000 people, Chatham-Kent is, mostly, a verdant mass of farming plots. If you follow the path of the river, you’ll pass the Thamesville Maize—a corn maze shaped this year in the likeness of astronaut Chris Hadfield—until you get to Chatham, a community of 44,000. In some places, Chatham is postcard pretty, its downtown core filled with red faux-cobblestone sidewalks and the kind of jaw-dropping Victorian brick homes that dot southern Ontario. Mostly, though, it is dominated by one-storey, vinyl-sided houses and low-density commercial strips—bars, pharmacies, pawnshops, and car dealerships.
The fortunes of Chatham-Kent have risen and fallen with those of southwestern Ontario’s automotive and manufacturing industries. Recently, they have mostly fallen; in its latest forecast, the Chatham-Kent Chamber of Commerce described the prospects for the local economy as “not promising,” citing a shrinking population and the exodus of heavy industry. The symptoms of that gloomy portrait are evident in the fabric of the place; although it’s designed for strolling and shopping, downtown Chatham feels almost abandoned when I visit. Meanwhile, back up the road in Thamesville, the only business that seems to be prospering is the Westover Treatment Centre, an addiction-recovery facility. Its massive front lawn is healthy and green, the august grounds evoking a well-to-do rural university. When I arrive, some clients are out for a walk; others sit on benches, gazing at the impressive converted mansion that serves as the centre’s main edifice.
According to those on the front lines of drug treatment, Chatham-Kent’s communities have, like much of Ontario, seen a steady rise in prescription opioid misuse over the past two decades. In 2007, almost 30 percent of high school students in the Erie St. Clair Local Health Integration Network, an area that includes Chatham-Kent, admitted to having used prescription opioids for non-medical purposes at least once in the previous year, according to the Ontario Student Drug Use and Health Survey. Although the survey documented a drop in prescription opioid misuse among junior high and high school students across the province between 2007 (20.6 percent) and 2013 (12.4 percent), it found that prescription opioids are still the fourth-most commonly used drug, after alcohol, highly caffeinated energy drinks, and cannabis.
There are many potential reasons for Chatham-Kent’s high rate of opioid misuse, perhaps including the region’s recent economic downturn. According to Ron Elliott, the executive director of the Westover Treatment Centre and a pharmacist by training, the spread of prescription opioid addiction is also due to a shift in prescription patterns over the last several decades. It’s gotten to the point, he says, that doctors are expected to provide the most efficient pain management available—even if it means putting patients at a higher risk of becoming addicted. As a pharmacist in the 1990s, Elliott saw physicians start prescribing huge amounts of painkillers, such as OxyContin. “It wasn’t unusual for someone being discharged from hospital to get a hundred doses of a pain reliever, rather than twenty or twenty-five to see how they do,” he says. “And so people became accustomed to having those larger orders on hand. We had some docs who wrote inordinate amounts. I was getting scripts at one pharmacy for five, six, even seven hundred doses of Oxys and that kind of stuff. And every time I challenged them—and I went through the system to challenge them—I was reassured that this is what’s always done.”
Elliott’s experiences were symptomatic of a larger trend. Between 2000–02 and 2010–12, according to data from the International Narcotics Control Board, Canadians’ consumption of prescription opioids—that is, opium-derived drugs like OxyContin and Percocet—more than tripled. That is a faster climb than in the United States, and one that turned Canadians into the second-highest per capita users of prescription opioids in the world, after Americans. Some observers say that this is a side effect of Canada’s robust universal health care system, though it can also be traced back to our historically poor regulation of painkiller dispensation. Pharmaceutical advertising targeted at physicians also slowly skewed the medical landscape, such that the over-prescribing of these addictive drugs became increasingly commonplace.
The expansion of OxyContin use also saw Purdue Pharma, the maker of the drug, attract the wrath of the justice system. In 2007, three top executives at Purdue pled guilty to “misbranding” OxyContin after aggressively marketing it to general practitioners while downplaying its addictive potential. As part of the same case, a holding company affiliated with Purdue pled guilty for fraudulently claiming that OxyContin was less addictive than other painkillers. Purdue also faced lawsuits in Canada and the US on the behalf of patients or their family members who felt misled about the narcotic’s dangers. In 2010, the University of Toronto came under fire after it was revealed that a lecturer in a pain management course offered students free copies of a book that Purdue had copyrighted and funded, raising concerns about a conflict of interest; the lecturer had also been a paid speaker for the company. The book reportedly contained several inaccurate statements suggesting that oxycodone, the generic formulation contained in OxyContin, was less potent than it actually was.
Even with these setbacks, the end result of this marketing strategy has been predictable—a massive expansion in the use of opioid-based prescription drugs across North America. In Ontario, which has the highest per capita dispensing rate for high-dose opioid painkillers in the country, the repercussions have been grave. Between 1991 and 2010, the province’s annual rate of opioid-related overdose deaths has jumped by more than 240 percent, from 12.2 to 41.6 deaths per million; by 2010, one in eight deaths among people between the ages of twenty-four and thirty-five was linked to opioids. In some Aboriginal communities in the north of the province, including Cat Lake First Nation, levels of opioid addiction are reportedly as high as 70 percent of the adult population. In short, Chatham-Kent is not alone, and Ontario’s painkiller problem has all the hallmarks of an epidemic.
As the visibility of the problem grows, recent attempts to address painkiller misuse have exposed the unanticipated hazards of trying to stop addiction and the markets that feed it. The rise of prescription opioid misuse is the latest in an unending cycle of self-medication, restriction, and market adaptation that appears immune to our efforts to control it. Instead, tightening the pressure on the market only seems to cause shifts from the use of one drug, like OxyContin, to others, like crystal meth. Our successes and failures in fighting Ontario’s painkiller epidemic, however, might just point to a way to end this cycle for good—by regulating illegal drugs the way we do prescription opioids.
I meet Lisa in the offices of Chatham’s community health centre, which is tucked into a nondescript building in a mini-mall parking lot. Now twenty-six, Lisa (not her real name) has been managing her painkiller addiction for seven years, with some real success: she’s enrolled in university and has regained custody of her three children. Beyond her manicured appearance and formal comportment, though, it is clear that she is still facing her demons. As we speak, her mother sits nearby, a pained look on her face.
For Lisa, prescription painkillers have always been part of the landscape of Chatham-Kent. “We would do Percocets in high school at gym class,” she says. This was in part due to their wide availability, but also because of a common misperception of prescription drugs. “There is a difference in how people look at them versus illegal drugs like meth or heroin,” she says. “With prescription drug use, people seem to look at it like it’s not as bad as illegal drugs—but it is. It’s almost worse. ”
Christopher Cartier, a coordinator at AIDS Support Chatham-Kent, sees the epidemic up close every day. His job involves handing out clean needles and other supplies to people who use drugs, but at twenty-three he’s also young enough to know what being a high school student is like in the prescription pill era. “I have noticed in the last few years that prescription drug use is increasing, especially among youth,” he says. “When they go to parties, it’s so easy to get them. You go into your parents’ cupboards, and you grab their pills.”
It is this pervasive abuse that finally prompted the federal, provincial, and territorial governments to turn their attention to the crisis—but agreeing on a strategy has proven elusive. After years of warnings and mounting evidence that prescription opioid misuse was killing Canadians, in February 2012 Purdue Pharma Canada announced that it would stop distributing OxyContin and replace it with a new formulation, called OxyNeo. (Critics have pointed out that this was likely motivated more by business concerns than by altruism, as the patent on OxyContin was set to expire less than a year after OxyNeo came to market.) Later that year, the provinces and territories pushed Ottawa to restrict access to oxycodone-based pharmaceuticals by delaying approval for generic forms of OxyContin. But Health Canada went ahead anyway, arguing that federal laws didn’t allow them to prohibit a pharmaceutical because of misuse.
For Ontario, reeling from a mounting death rate (some statistics suggest that ten Ontarians a week were being killed by prescription painkillers), inaction was not an option. So at the same time that Purdue heralded OxyNeo’s arrival, the province announced that, in order to limit prescription rates, the drug would be available only through the Exceptional Access Program and the Facilitated Access to Palliative Care Drugs mechanism. Later that year, Ontario also placed restrictions on oxycodone-based drugs in anticipation of the patent for OxyContin expiring.
While OxyNeo is supposedly safer than its forerunner, Purdue cannot claim that it is tamper-resistant without approval from Health Canada. However, it is widely acknowledged that the new product was designed to be more difficult to break down and consume by snorting or injection. That means, in principle, that the potential for its abuse is limited, since its slow release wouldn’t satisfy people who were addicted to opioids. But these built-in controls, it would turn out, might have been too effective.
Drug users in Chatham-Kent tried their best to overcome OxyNeo’s supposed resistance to tampering. “Some people thought that if you froze them, then you could somehow change the effect—but you can’t,” Lisa says. As well, the removal of OxyContin from the market wasn’t implemented as an isolated measure. Rather, it is part of a larger approach, which includes a system to track opioid dispensation across the province using government-issued IDs in an effort to curb drug seekers from going to several doctors and getting multiple prescriptions for narcotics.
Still, removing crushable OxyContin from the menu of narcotics available on the street hasn’t meant that the appetite for prescription opioids has disappeared. Elliott believes that placing restrictions on what was previously a huge supply of diverted painkillers might actually spell long-term trouble. “The constraints will cause people to find alternatives, just like any other kind of prohibition,” he says, pointing out that people turned to moonshine and rum-running during Prohibition. Economies, just like nature, abhor a vacuum. It’s no surprise that the sudden cessation of OxyContin distribution sent shock waves through Ontario.
In Chatham-Kent, the local drug market moved into darker territory. Unable to stave off their withdrawal with OxyNeos, people dependent on prescription opioids sought new and more dangerous ways to manage their addiction. The use of fentanyl—a drug that is fifty to 100 times more powerful than morphine, with a high risk of overdose death—increased. Constable Jeff Teetzel of Chatham-Kent’s Drug Enforcement Unit has seen this market shift first-hand. “A lot of the search warrants that we’re doing now are specifically for fentanyl,” he says, noting that over the past two years fentanyl trafficking in the region has replaced much of the business in OxyContin. “It’s becoming the top money-maker here.” This is a stark change from five years ago, Teetzel says, when fentanyl wasn’t even on the police drug squad’s radar.
According to the Chatham-Kent police department, there have been seven deaths related to fentanyl misuse since 2011; that includes one in 2013 and three so far this year. But the shift away from OxyNeo wasn’t limited to fentanyl. “It was basically whatever you could get your hands on,” Lisa says, shaking her head. “Meth is a terrible drug.” Between 2012 (when OxyContin was discontinued) and 2013, the number of people charged with meth trafficking in Chatham-Kent increased, even though the overall number of people charged with drug violations decreased slightly.
The unintended blowback of meddling with illegal drug markets is so well documented that it has its own name in the scientific literature: the balloon effect. The term comes from the way that if you poke a balloon in one place, the air moves to another. It’s a useful analogy for how drug markets react to pressure, and it has proven axiomatic at every level—from production to trafficking to use. One of the best-known examples comes from South America, where, beginning in 1989, the US spent billions of dollars to eradicate coca in Bolivia and Peru, only to see cultivation move into Colombia, where the cocaine business had previously focused on manufacturing and export. In late 2000 and early 2001, Australia saw a huge but short-lived drop in the supply of heroin available in the country. The cause of this so-called drought is a matter of debate, with some experts claiming it was due to the success of Australian policing and others suggesting it had more to do with global disruptions in the heroin market. Whatever the reason, while the drought caused a pronounced decrease in heroin, it wasn’t long before researchers noticed that the use of other drugs, such as methamphetamines, had increased. The balloon, so to speak, changed shape but remained full.
It’s no surprise then that Chatham-Kent saw its illegal drug market shift to fill the vacuum created by OxyContin’s absence. Lisa witnessed how savvy dealers used doctors to continue diverting drugs onto the street. Before OxyNeo was introduced, she had a boyfriend who had suffered a back injury and was being prescribed huge amounts of painkillers. “He was being prescribed eight eighty-milligram OxyContins, a 100-milligram fentanyl patch, and 100 milligrams of methadone pills a day,” she says. “All he took was the methadone. He’d sell everything else and was making a ridiculous amount of money.” When OxyNeo replaced OxyContin, the boyfriend found he couldn’t sell it. “So he went in and told the doctor, I have this huge stomach pain and can’t be on them,” she says. “The doctor just doubled him up on his fentanyl patches, and he was selling those.” Fentanyl is now big business; according to Teetzel, just one patch is worth about $400 on Chatham-Kent’s black market.
The market shock came earlier for Gary, a weary, deliberate man who recently checked himself into the Westover Treatment Centre. A recovering alcoholic, Gary (not his real name) developed an opioid addiction after his wife suffered a herniated disc and he began dipping into her prescriptions. Soon, he was taking sixteen to twenty Percocets and one to two Oxys per day—a habit he kept up for years. Then, in 2011, his wife’s prescription ran out. By then, though, the sheer volume of opioids that he had consumed made it physically impossible to quit cold turkey—the withdrawal symptoms were too crippling.
Gary experienced the balloon effect on a micro scale. With no more access to opioids, he switched to self-medicating with a familiar substance—alcohol. “By the end of it, I was bouncing between alcohol and prescription meds, jumping from one addiction to the other to try to manage the withdrawal from either one,” he says. Aware that his family would suspect him if he smelled of alcohol, he sought other options, finally settling on a habit of sixty over-the-counter Tylenol pills a day. When that wasn’t enough, he got painkillers however he could, including stealing from a friend’s medicine cabinet. A bit sheepishly, he admits that he also thought about buying illegal drugs. “But I didn’t know the streets, didn’t know the connections, didn’t know how to access them,” he says. Gary’s alcohol abuse was much harder to conceal from his family, though, and the latest chapter in his battle with addiction began with an intervention from his wife and kids, and a trip to the Westover Treatment Centre.
Opioid addiction, while painful and complicated, can be managed. One of the best tools we have is methadone maintenance therapy, an oral medication taken as a liquid. Methadone attaches to the brain’s opioid receptors and reduces the body’s craving for opium-derived substances like heroin or OxyContin. Although it has its limitations, methadone can be effective. In Lisa’s case, it allowed her to begin to rebuild her life, but it initially wasn’t easy to access the therapy; the closest clinic was in Sarnia, forty-five minutes away. “I had to go there every day to get a dose at a Shoppers Drug Mart,” she says. “It was kind of embarrassing: you had to take a drink in front of people.”
The arrival of a methadone clinic is usually accompanied by not-in-my-backyard outrage, with anxious local residents taking to the media to voice their fear of addicts invading the neighbourhood. But a funny thing happened when Wallaceburg—a community of 10,000 people in Chatham-Kent riven by prescription opioid and meth addiction—opened not one but two clinics. “It’s an automotive-industry town where the industry has pretty much entirely disappeared, and there’s a high rate of unemployment,” says Janet, Lisa’s mother. “And that’s led to the addiction rate being very, very high. So when the clinics opened, you didn’t hear a thing.”
There are currently four methadone clinics in Chatham-Kent—two in Wallaceburg and two in Chatham. They’re clearly marked, but they nevertheless seem to fade into the background. The building that houses the Bluewater Methadone Clinic in Wallaceburg, for instance, sits in a low-density commercial zone alongside a Goodwill Donation Centre and a bingo parlour. While it’s surprising to see so much investment in addiction treatment for such a small population, the need clearly exists. “There’s a great big sign outside one of the methadone clinics in Wallaceburg that says, ‘We’re open and taking patients.’ It even has the word methadone right on it,” Lisa says ruefully. “I guess it kind of tells you how bad the addiction has gotten that they felt that they could make enough money with two methadone clinics in this very small town.”
For his part, Elliott believes that any contingency plans put in place to deal with the symptoms of opioid addiction are likely to fail. That’s partly because his experience as a pharmacist exposed him to the profit motive that drives the prescription of these drugs in the first place. The same economic forces that allowed fentanyl to fill a void in Chatham-Kent’s diverted painkiller market, Elliott says, are already spurring pharmaceutical companies to produce new opioids. “The problem we had with OxyContin will continue,” he predicts. Indeed, despite Ontario’s 2012 restriction, the federal government approved the distribution of a generic form of OxyContin by an Indian pharmaceutical firm in late 2013.
The larger issue, Elliott suggests, isn’t the motives of pharmaceutical companies, but a deep institutional reliance on opioids. Doctors are gaining a better understanding of the addictive potential of this class of pharmaceuticals. However, government drug plans tend to cover opioids, but not non-opioid alternatives or rehabilitative services such as physiotherapy, which would require private insurance or paying out of pocket. This dramatically limits the range of pain management choices available to patients. Until Health Canada regulations change to include more analgesic options with less addictive potential than opioids, Elliott says, communities like Chatham-Kent will be hard pressed to stop the painkiller epidemic.
Our traditional response to illegal drug use has been based on a simple premise: if something is dangerously addictive, we should prohibit it. But—as with Chatham-Kent, and places as far flung as Australia and Colombia—shutting down the supply of one drug won’t destroy the markets that feed on addiction. It simply means that users will move en masse toward a new form of self-medication. Prescription drug abuse adds a political complication to this scenario. While it may be easy to condemn crack or meth dealers, there are fewer convenient sound bites to fall back on when the substances in question are coming from your community’s pharmacy. For that matter, Constable Teetzel and the Chatham-Kent drug squad can’t prevent government plans from continuing to cover opioid-based pain medication, which some patients legitimately need. And when provinces put restrictions on OxyContin only to see the federal government approve generic forms of it months later, there is little that our criminal justice system can do.
The response to Ontario’s painkiller epidemic has demonstrated that when a drug is regulated, the stigma that clouds our view of addiction stops being a factor. The 1980s had crack babies; the 1990s had ecstasy raves; the 2010s have had breathless reporters claiming that taking so-called bath salts will make you eat someone’s face. Each Reefer Madness moment did little except further stigmatize those who use drugs. But the prescription-opioid problem has been different. Instead of the knee-jerk, tough-on-crime catchphrases that our elected leaders spout when they talk about illegal drugs, we’ve seen humane, sympathetic policies put in place that have the potential to meaningfully stop prescription-opioid diversion and abuse.
In Ontario, some of those policies have already worked. The province requires every patient receiving prescription opioids to have an identifying number that allows the government to track dispensation patterns, so that prescriptions don’t get out of control. The College of Physicians and Surgeons of Ontario has been working to better educate physicians on safer pain management, as well as advising the government on building policies to prevent diversion. And a new online tracking tool will allow Ontario health officials to immediately know when the number of opioid overdoses is rising, instead of waiting a year or more for statistics to be compiled by the ministry—information that could allow the government to nimbly respond to opioid deaths rather than play catch-up.
Still, there’s a disturbing corollary to this success story. Addiction can be surprisingly flexible, as seen in the shift from Oxy to fentanyl, or Gary’s vacillations between Percocet and alcohol. This means that any anti-diversion strategy that starts with a unilateral clampdown on prescription opioids might do more harm than good. In Chatham-Kent, there has been an uptick in crystal meth trafficking and an increase in fentanyl-related deaths since OxyContin was discontinued. The balloon effect is in full swing. Even if painkiller diversion ceases entirely, it could very well be accompanied by a sustained shift toward meth, heroin, and other drugs.
So how do we tackle the frustrating fluidity of drug markets and the addictions they serve? The answer might lie in our policies around pharmaceutical dispensation. Despite lax restrictions, there is still a paper trail tracking every pill that doctors prescribe; as the government moves to stem diversion, this paper trail will be the key to ensuring that all pills are accounted for. But once users shift to illegal substances, the paper trail ends. There are no receipts issued by street-level dealers, or tools for drug users on the street to gauge the potency of the substances they’re buying—or for that matter to know what those substances are. The end result is that our granular understanding of the size and composition of the markets in communities like Chatham-Kent will vanish. While we will likely see fewer people addicted to painkillers, we will also lose sight of what they’re turning to when prescription drugs run dry.
That’s why any strategy that focuses only on prescription medications—or only on marijuana, crack, or heroin, for that matter—is doomed to fail. There will always be other drugs, other ways to get high, and groups of people more prone to self-medicating than others. Without a way to address the root causes of addiction, the balloon effect will make sure that people who want drugs will find them. Sadly, we know that trauma, mental illness, and sexual abuse are among the factors that can increase the risk that people will self-medicate, but our policies mostly focus only on limiting drugs’ availability. Narcotics laws have created illegal, multibillion-dollar markets for heroin, cocaine, crystal meth, and marijuana, all of which are outside of the purview of the state. Nothing the war on drugs has thrown at them, including mandatory jail time, police crackdowns, drug seizures, and anti-drug ad campaigns, has made them disappear.
Compare this failure with the flexibility of our policies around prescription opioids, which can be modified, as we’re seeing, on the fly. The very fact that we regulate prescription opioids provides governments with an array of policy options that can be put in place quickly to control their diversion: better education on pain management for doctors; stricter rules on prescribing; and more stringent pharmacy dispensation guidelines, to name a few. When these kinds of regulations are paired with a medical system that expertly recognizes and treats addiction, those who self-medicate can finally be helped to stabilize their lives. Meanwhile, our policies to control the flow of illegal drugs continue, predictably, to founder.
Imagine, though, that instead of simply letting people addicted to prescription drugs fall into the world of illicit narcotics, we took one more profound, albeit controversial step. Instead of simply improving painkiller regulation, what if we made it the responsibility of our governments to regulate the flow of equally dangerous drugs like heroin, crack, and crystal meth? What if we could shape illegal drug markets with the same kind of controls with which we shape access to prescription medications?
It sounds, perhaps, a little far fetched, but similar approaches have been implemented elsewhere. For example, since Portugal decriminalized drugs in 2001, there has been a decline in drug-related deaths and fewer new cases of HIV, according to a report by journalist Glenn Greenwald for the Cato Institute, a libertarian think tank in Washington, DC. Of course, decriminalization is one thing; regulating illegal drugs as we do pharmaceuticals is another. Even so, research from Canada and a host of European countries has shown that regulating heroin under a prescription model can help stabilize the lives of opioid-dependent people, encourage health improvements, and reduce users’ risk of death. A clinical trial conducted in Vancouver and Montreal, called the North American Opiate Medication Initiative, or NAOMI, provided 115 long-term users of heroin with injectable diacetylmorphine (the active ingredient in heroin) in a medically supervised environment between 2005 and 2008. After a year, patients reported improvements in medical and psychiatric status, employment, and family and social relations. Two-thirds of the patients also saw significant reductions in street-drug use or other illegal activities. In short, prescribing heroin in a medically supervised environment helped the study’s participants stabilize their lives and, in many cases, control their addiction—something that methadone had not previously allowed them to do.
The NAOMI model is one among many that we could use to regulate illegal drugs—and one that could go hand in hand with the kinds of enhanced restrictions we’re seeing around the dispensation of opioids in Ontario. If our efforts to manage access to legal painkillers are successful, surely we should take those lessons and apply them to all drugs. That would mean, of course, asking our governments to assume control of the markets for illicit substances like heroin and cocaine, and putting in place creative approaches, like the one pioneered by the NAOMI trial, to contain the harms they cause to society. While this gambit isn’t without risk, it may be the only way to stop the ongoing cycle of addiction, and puncture the balloon once and for all.
As of 2012, according to a Global News analysis of health ministry data, prescriptions for OxyNeo in Ontario hover at around 60 percent of what those for OxyContin were when it was discontinued. Only about 25,000 scripts for the new formulation were recorded in December 2012, which might suggest that the increased restrictions and new formula were working to reduce misuse. Fentanyl prescriptions in the province, though, have remained relatively steady—about 20,000 per month—and the drug is still easily accessible. It will likely be some time before the flood of prescription opioids abates. Economic decline, an aging population seeking pain control, youthful peer pressure, and feelings of social dislocation will ensure that a ready market for painkillers, whether illegal or legal, remains.
For Ron Elliott, tackling drug addiction is about honing in on a basic question. “Set aside all the rules,” he says. And have people ask themselves, Why am I using? Maybe, if we can extend what we’ve learned about controlling prescription opioids to the entire drug market, we might finally be able to find the answer.
This appeared in the December 2014 issue.