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A Toxic Soup of Painkillers - Thoughts on the Opioid Epidemic

Dear editor,

The opioid epidemic that is gripping North America is an emerging issue for Nova Scotians and for our health-care system. Misuse of opioids, such as hydromorphone, oxycodone and morphine, has been a significant problem in Nova Scotia for more than a decade. And now fentanyl and carfentanil are making their way into our communities. How did we get here?

When I first started practising medicine in the 1990s, the focus when treating chronic pain was to improve function with physiotherapy, occupational therapy and other non-medicinal treatments. Painkillers, anticonvulsants and antidepressants were all used, but opioids were used sparingly, if at all. With a focus on function, most physicians were reluctant to prescribe opioids – the risk of long-term dependence was not worth the short-term benefit.

But during the mid-1990s, opioid prescribing patterns shifted. Whereas opioids had previously been used only for acute and palliative care and cancer pain, drug companies now advised physicians that opioids were appropriate for treating patients with chronic non-malignant pain.

Last year, Canadian physicians wrote 22 million prescriptions for opioids; Canada is now the second-largest consumer of opioids in the world. And the cost is real: Almost 500 patients have died as a result of an opiate overdose in British Columbia this year, with Alberta and Ontario seeing similar numbers. More than 800 Maritimers have suffered an opiate overdose since 2008. In the U.S., President Obama has held public meetings on the topic. The American Surgeon General started “Turn the Tide Rx,” a campaign to end the opioid crisis. The Centers for Disease Control and Prevention have published – and many medical regulatory bodies have endorsed – prescribing guidelines for opioids for chronic pain.

Yet opioid overdoses and deaths continue to climb. One reason is that combining drugs such as alcohol, benzodiazepines, opioids, ecstasy and cocaine is frequently deadly. Another reason is that the opioids people are obtaining illegally are changing.

As health-care professionals have become more aware of the opioid epidemic, there has been an effort to decrease prescribing opioids to patients with chronic non-malignant pain. But as physicians decrease dosing, some patients seek opioids from other sources, especially the street.

Street drugs have changed. Prescription opioids frequently end up on the street, but now heroin, fentanyl and carfentanil are being mixed to create look-alike pills. Fentanyl is 100 times stronger than morphine; carfentanil is 10,000 times stronger than morphine. There are 100 lethal fentanyl doses in a tablet the size of an Aspirin; a dose of carfentanil the size of a grain of salt will produce a fatal overdose.

Every effort needs to be made to inform the public of the dangers of these drugs. First-responders and community workers need training and access to naloxone, a drug that can help reverse an overdose. More resources will be needed for addictions and associated mental health problems. First Nations communities, which are often disproportionately affected, will need additional support.

The medical profession needs to acknowledge its contribution to the problem and take responsibility. It’s time to rethink our approach to pain and medication, and help lead our communities out of this epidemic.

DR. DAVID MILNE
Associate Chair, Department of Anesthesia, Pain Management and Perioperative Medicine and Past President of Doctors Nova Scotia
Follow me on Twitter for more on the opioid crisis: @DavidMilne9