Prescription opioid addiction raises concerns

Tuesday, November 4, 2014

The rate of opioid-related deaths in Canada has reached epidemic proportions. In Ontario alone, these deaths increased 242% between 1991 and 2010. The 203% increase in pain medications prescribed in Canada between 2000 and 2010 definitely had something to do with it. And the epidemic will likely continue to rise because, in 2013 alone, Canadian pharmacies filled 19 million opioid prescriptions—almost three million more than in 2010.

Over the last 15 years, opioid abuse and addiction has become a major public health issue. Canada is now ranked second in the world, after the United States, for per capita use of prescribed opioids. Health Canada has issued a warning about the use of opioid pain medications, and it has just changed its labelling to limit their use to severe pain. For good reason: these substances are effective pain relievers, but they can have serious health effects because of their risk for addiction and death by accidental overdose.

Some statistics

Even though there aren’t a lot of statistics on opioid-related deaths, the few stats available raise concerns. Between 1991 and 2010, 6,000 Ontarians (half of whom were under age 42) died from opioid overdoses—a 242% increase. Ontario has the highest rate of high-dose opioid prescribing; in 2012 alone, it reported 600 opioid-related deaths—more than 11 a week. This year, a report by the Canadian Drug Policy Coalition revealed that opioid-related deaths are now the third leading cause of accidental death in Ontario. Quebec also saw a gradual increase in the rate of fatal opioid overdoses between 2000 and 2009. British Colombia reports that 87% of the people who died from opioid overdoses between 2006 and 2011 were under age 60, and 82% of them suffered from chronic pain.

The 203% increase in opioids prescribed in Canada between 2000 and 2010 definitely had something to do with these deaths. A public report released last September also revealed that high-dose prescribing, which increases the risk of accidental overdose or death, went up 25% between 2006 and 2011. And things aren’t likely to improve anytime soon: close to 20 million opioid prescriptions were filled in Canadian pharmacies in 2013; that’s almost three million more than four years ago.

Things aren’t any better for our neighbours to the south, either. The Centers for Disease Control and Prevention revealed that in 2010, 60% of overdose deaths in the United States were linked to prescribed opioids. Pain medications cause more deaths in the US than heroin and cocaine put together. Vermont has been severely affected: since 2000, it has seen a 770% increase in the number of individuals being treated for opioid addiction, and the number of overdoses has doubled in the past year.

What is an opioid?

Commonly known as “analgesics” or “narcotics,” opioids are natural components of opium or synthetic derivatives of psychotropic opiates. The most popular ones are morphine, codeine, oxycodone, fentanyl and hydromorphone. They’re often prescribed to relieve patients suffering from cancer or those with moderate to severe chronic pain, or to soothe a persistent cough. Some, like methadone, are used to treat opioid addiction without the “high”. But regardless of how they’re taken, opioids enter the bloodstream and interact with proteins called “opioid receptors” in the brain, the spinal cord and the gastrointestinal tract. They produce this high because they help reduce neuronal excitability.

In Canada, prescription opioids are mainly sold as tablets, capsules, syrups, injectable solutions, transdermal patches, suppositories and nasal sprays (see Examples of prescription opioids at the end of this article).

How are they dangerous?

Opioid analgesics are effective pain medications. Side effects (e.g. drowsiness, nausea, constipation, loss of appetite) are manageable if the instructions are followed. However, the enhanced sense of well-being or euphoria they cause can sometimes lead to overdose and addiction, with serious health consequences. In high doses, opioids can cause drowsiness and even induce coma or death.

Accidental overdose occurs when a drug is not taken properly. For example, if the pills are crushed and then injected or inhaled, too much of the substance is consumed at once, causing drowsiness, coma and even death if the person doesn’t receive treatment. Ottawa plans to force opioid manufacturers to reformulate their products so they can’t be easily crushed, inhaled or injected.

Injected crushed opioids can cause permanent vein and organ damage. The risk of overdose is also related to the tolerance that individuals develop as they continue to increase their dose to produce the euphoric effect.

Social effects of addiction

Addictions can develop in individuals taking prescription medications (who exceed the prescribed dosage, take it longer than expected or take it with other drugs or alcohol) as well as in those who decide to self-medicate or take the drug recreationally. When someone with an addiction can’t get a prescription, they’ll be tempted to buy the drug on the black market or online, or turn to other, less expensive opiates or illegal drugs.

Opioid addiction affects young and old alike, and individuals with a personal or family history of drug addiction and alcoholism are more vulnerable. In 2012, the Canadian Alcohol and Drug Use Monitoring Survey revealed that 410,000 Canadians have abused prescription drugs such as opioid pain medications, stimulants, tranquilizers and sedatives.

Opioid addiction and abuse often cause problems at work, school and home. Abusing prescription drugs also increases societal costs because of the impact on productivity, the healthcare system and crime.

Domino effect on the black market

In 2010, Purdue Pharma, the maker of the very popular OxyContin (oxycodone), was forced to reformulate the drug to make it hard to inhale or inject. It’s now hard to find OxyContin on the black market, as it’s been replaced by OxyNeo, which is more difficult to crush into powder and inject (it becomes gel-like when you add water). It’s probably why heroin has seen a resurgence in popularity, since it’s stronger and less expensive.

People have also turned to fentanyl, a pain medication that’s 40 times stronger than heroin and 50 to 100 times stronger than morphine. Just a few micrograms make the difference between a “correct” dosage of fentanyl and a fatal one. Last May, 15 deaths linked to this substance were reported in Quebec alone.

How is opioid addiction treated?

It’s practically impossible to treat addiction on its own. When an individual who has become addicted stops taking the drug, they feel pain everywhere in their body, because their brain has stopped secreting endorphins, which are natural opioids that ease pain and regulate vital functions. Opioids replace endorphins, which are the feel-good hormones our bodies produce naturally. The brain understands that it no longer needs to secrete these hormones and stops making them. Substitution drugs like methadone and suboxone (a synthetic opioid that’s similar to methadone) suppress the symptoms associated with opioid withdrawal by replacing the endorphins that are no longer secreted by the brain, without causing euphoria. They have been shown to be effective in treating addiction, even though they’re still controversial. Also, the cost of a full methadone maintenance program is $6,000 a year per person, whereas the annual cost of non-treatment is an estimated $44,000 per person in Ontario.

How to reduce the risks of addiction or abuse*?

Before taking opioid pain medication, you should:

  • Discuss the benefits and risks with a healthcare professional
  • Tell your physician or pharmacist about other drugs you’re taking to avoid potentially harmful drug interactions
  • Tell your physician about any personal or family history of substance abuse
  • Read the labels and follow the instructions exactly
  • Consult your pharmacist if you miss a dose
  • Don’t crush time-release pills
  • Keep opioid pain medications out of the reach of children and adolescents
  • Keep track of the quantity of opioids you have on hand
  • Never give opioid pain medications to other people; it’s illegal and it can have serious health consequences
  • Return any unused opioids to the pharmacy for safe disposal.

*Taken from Health Canada’s website

Examples of prescription opioids
Active opioid ingredient1Product name
BUTORPHANOL
  • APO-BUTORPHANOL
  • PMS-BUTORPHANOL
CODÉINE
  • ATASOL
  • CONTROLLED-RELEASE CODEINE
  • COACTIFED
  • EXDOL
  • TYLENOL WITH CODEINE
FENTANYL
  • DURAGESIC
HYDROCODONE
  • DALMACOL
  • HYCODAN
  • TUSSIONEX
HYDROMORPHONE
  • DILAUDID
  • CONTROLLED-RELEASE HYDROMORPH CONTIN
  • HYDROMORPH IR
MÉPÉRIDINE
  • DEMEROL
MORPHINE
  • DOLORAL 1 (syrup and wafer tablets)
  • MS CONTIN
  • M-ESLON
  • KADIAN
  • STATEX
OXYCODONE
  • OXY.IR
  • OXYCONTIN
  • OXYNEO
  • PERCOCET
  • PERCODAN
  • ENDOCET
  • SUPEUDOL
PENTAZOCINE
  • TALWIN

1 These drugs may contain other ingredients. Only opioid ingredients are shown in the table.

Table created using information from Health Canada.

Reference documents and websites

Canadian centre on substance abuse, Prescription Opioids, summer 2013

Health Canada

Canadian press, Health Canada changes opioid drug labels, August 18, 2014.

Bérubé, Nicolas, “Le Vermont accro à l’héroïne,” La Presse, February 2, 2014.

Institut national de santé publique du Québec, Décès attribuables aux intoxications par opioids au Québec : 2000 à 2009, octobre 2013.