Call it medically induced and law-abiding addiction. Experts says it’s harder to kick than heroin and they’re so astonished by its growing incidence that they’re arguing for Canada to move immediately with a strategy to constrain its future effects on the health care system and the health of Canadians.
Prescription opioid addiction appears to have been dangerously underestimated, says Irfan Dhalla, a University of Toronto researcher and member of the advocacy group, Physicians for Responsible Opioid Prescribing, pointing to a recent study of 705 United States outpatients undergoing long-term opioid therapy for noncancer pain at Geisinger Health Centers, a health care system in Danville, Pennsylvania (J Addict Dis 2011;30:185-94). It found that 21.7% met the standard criteria for moderate opioid-use disorder, while 13.2% met the criteria for severe opioid-use disorder.
Those staggering percentages have Dhalla and others calling on Ottawa to launch a coordinated national strategy on prescription opioid addiction as part of its revisions to the national antidrug strategy. “Health Canada and the federal government should be much more actively involved in efforts to reduce harm from prescription opioids,” says Dhalla. “The FDA [Food and Drug Administration] and the White House in the US are doing much more than their counterparts in Canada. Health Canada could consider making changes to product monographs and even withdraw approval for formulations that routinely lead to doctors prescribing very high doses.”
Benedikt Fischer, director of the Centre for Applied Research in Mental Health and Addiction at Simon Fraser University in Vancouver, British Columbia, wants the federal government to go even further, by making prescription opioid control “a central focus and component of a next iteration of a National Drug Strategy,” or “the focus of its own specific strategy of interventions and programs, allowing comprehensive and concerted action.”
Researchers are concerned that vast numbers of “medically dependent” opioid addicts are being created simply by following doctors’ orders.
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Fischer and Jürgen Rehm, director of the Social and Epidemiological Research Department at the Centre for Addiction and Mental Health in Toronto, Ontario, warned the federal government in a recent report to the Department of Justice that Canada isn’t doing enough to track opioid abuse or treat medically induced addiction.
Canadians are among the highest users of prescription opioid in the world, Fischer and Rehm say, adding that their report informed the government that overall usage of prescription opioids has more than doubled over the past decade.
While widespread use of illicit opioid use has been widely reported, the researchers say they are increasingly concerned that vast numbers of “medically dependent” addicts are being created simply by following doctors’ orders. “I think it’s fair to say that the number of patients who develop an addiction in Canada is sufficiently high that prescribers and public health authorities should be concerned,” says Dhalla.
Joseph Boscarino, who led the Geisinger study, was surprised and alarmed to find that as many as one in five long-term noncancer patients using opioids develop moderate to severe dependency. “If you look at the demographics in our sample, this mostly involves older women living in suburban and rural areas,” he says. “It’s not your classic inner city-dwelling drug addict. These are people who are at potential risk [of addiction] but have never before been exposed to these drugs and are now getting exposed. And many of those who are at risk are going to succumb to the addiction.”
The study has helped fill gaps in estimating the prevalence of prescription opioid abuse among primary care patients, says Michael Von Korff, a senior investigator with the Group Health Research Institute in Seattle, Washington.
“These are old drugs but they haven’t been widely studied. There hasn’t been a lot of high quality research. But the word is now starting to get out.”
“These are people getting opioids legally, from a physician. It’s a significant problem,” he adds, estimating that as many as one million of the eight million Americans using prescription opioids are now medically addicted — and perhaps twice that amount if the Geisinger study is accurate.
It’s slowly forcing some painful soul searching in pain management circles, Von Korff says.
An educational video produced by Physicians for Responsible Opioid Prescribing includes information from a drug manufacturer asserting that “the rate of addiction amongst pain patients who are treated by doctors is much less than 1%” (www.responsibleopioidprescribing.org/educational/index.html).
But that estimate “was a gross misinterpretation, not just by the manufacturer ... but by the so-called thought leaders who were in positions of eminence, and some of our professional organizations and the pain management community who allowed that myth to perpetuate itself by misinterpretation of those data,” charges Nathaniel Katz, director of the Center for Opioid Research at the Massachusetts General Hospital, in Boston, Massachusetts.
Dhalla says there’s no compelling reason to believe that medically induced addiction rates in Canada are dramatically different from those found in the US.
But Canadian data are sparse and inexact, says Rehm, who nearly a decade ago estimated that the number of illicit prescription drug users in Canada was between 300 000 and 900 000 (Can J Public Health 2009;100[2]:104-8)
As many as 200 000 Canadians are currently addicted to painkillers, Rehm estimates, adding that he’s equally discouraged that evidence-based best practices for treatment of medically induced addiction do not exist.
The doubling in the number of Ontarians seeking treatment for prescription opioid abuse since 2005 and the tripling in the number of patients now undergoing methadone treatment are indicators of troubles to come, he adds. “And we need to keep in mind that addiction to prescription opioids is a chronic relapsing disease.”