Ask the Doctor: A lost battle in our War on Pain

I borrowed this title from the thoughtful article by André Picard, published in The Globe and Mail on March 6, 2012. This was one of the most sensible pieces of journalism I have read in quite a while in addressing the inappropriate use of prescription narcotics.

Picard comments on the March 1, 2012 replacement of OxyContin, a powerful pain killer, with OxyNEO. OxyNEO is a chemically identical but tamper-resistant version of the drug. OxyContin and other powerful opioids provide addicts with a “high,” particularly when their route of administration is altered, by crushing, snorting, or injecting it, instead of just swallowing it. Along with the disappearance of OxyContin in the form we have come to know, a number of provincial and federal drug plans have “de-listed” OxyNEO, leaving it out of public drug plans. While most patients already taking OxyContin will be able to get OxyNEO for a transitional period of up to a year, it will be very difficult for new patients to get the drug unless they are being treated for cancer. In some provincial plans, including Ontario, patients will still be able to get OxyNEO after the transitional period, but only if the physicians fill out lengthy paperwork many months before the expiry of the transition period. This is something that in all likelihood won’t occur.

These changes plunged a large number of people into chaos: physicians who do not know what to do, legitimate patients who take this drug with good pain control, and addicts who take it to get “high.”

Governments did this presumably to avoid the soaring cost of OxyContin prescriptions and to curtail abuse. On the surface this looks like a good change in public policy. But is it? Let’s see how these events unfolded:

  • OxyContin discontinuation was initiated by Purdue Pharma, the company that makes the drug, as regulators and academics have regularly asked the pharmaceutical industry to come forward with tamper-resistant versions of medications. The switch to the new OxyContin (called OxyNEO in Canada and re-formulated OxyContin in the United States) had already happened in the US over a year ago. American websites for those addicted to the drug had already gone on advising their “followers” that the “good stuff still existed in Canada,” but this is no longer the case.
  • Clearly, consumption of the drug was going to be reduced as OxyNEO is disliked by addicts. The industry was well aware of this and they proceeded to create newer formulations exactly to curtail the problem of abuse, by providing a safer drug.
  • Did the switch happen abruptly? Absolutely not. Governments were warned many months before the switch by the company, who indicated that supplies of old OxyContin were limited and were to be withdrawn from the market at a set date. They were also warned of the potential fall-outs and the need for education for physicians and pharmacists.
  • Without adequate preparation of physicians, pharmacists, and legitimate patients, chaos ensues. Physicians have not been trained to switch or reduce OxyContin for their patients, addicts are left without supplies, pharmacists are worried about robberies, and legitimate patients are looked upon as villains and abusers. Indeed we have seen a couple of deaths in Ontario where patients have been switched to other opioids by physicians who were not trained or informed on the correct procedures.
  • As for governments and their plans to save money, what is the actual reality? Certainly not the one they thought it would be. Other highly addictive opioids, such as hydromorph (Dilaudid) and fentanyl (that comes in the form of a patch), are still covered by government plans. Addicts are switching in droves to those drugs, which are still paid for by public money.

To sum up, what happened is not good public policy unless all aspects of the problem are addressed. Otherwise new problems are created.

As I have said so many times before, opioid overprescribing, abuse, and diversion are symptoms of a disease, not the disease itself. Regulations and impositions, alone, do not work. You need education of providers and patients, mental health and addiction services, interdisciplinary care, options for treatments (using opioids, drugs that are alternative to opioids, but also non pharmacological approaches), access to proper care from the primary level to specialists, provision of expert help lines for physicians and telemedicine for remote areas, self management approaches and preventative strategies, and the list goes on. All can be summed up with one line — a Comprehensive Pain Strategy for Canada and its provinces.

Angela Mailis Gagnon, MD, MSc, FRCPC(PhysMed)
Director, Comprehensive Pain Program,
Senior Investigator, Krembil Neuroscience Centre
Toronto Western Hospital,
Chair ACTION Ontario