Good morning. Thanks for the opportunity to present.
By way of introduction, I'm a physician. I specialize in internal medicine and pharmacology. I'm not a specialist in addiction. I'm not somebody with extensive public health training, but I do a fair bit of research in the field of drug safety, and over the last seven or so years this problem has become a major preoccupation of mine.
I'll just share with you some reflections on the problem as I see it. I apologize if you've heard some of these things before.
In the early 1990s, I was a pharmacist in Nova Scotia. I trained there, and during medical school and my internship I practised as a pharmacist. I worked in about three dozen pharmacies across the province. It was the case then that when patients came to the pharmacy with a prescription for morphine, they had cancer.
By the late 1990s, when I was finishing my internal medicine training, things had changed quite a lot. We saw OxyContin—a drug that is 1.5 to two times more potent than morphine—prescribed very liberally for chronic back pain, hip pain, osteoarthritis, fibromyalgia, and you name it. It was even doled out for minor ankle injuries. This happened because physicians were taught that it was safe and effective to use opioids for chronic pain.
Most physicians had no reluctance to give opioids to patients at end of life or to patients whose femur was sticking out of their leg, but the chronic-pain market was huge, and every day doctors were faced with patients with pain and we had reluctance to use the other drugs at our disposal. Acetaminophen—Tylenol—just doesn't work very well. The other drugs—anti-inflammatories—had all kinds of horrible side effects. We've all been burned by patients who had bowel problems or kidney problems as a result.
So the message that we could use these drugs, and we should use these drugs more liberally, was one we were quite happy to hear. The important thing to realize is that that message came directly and indirectly from the companies that make these drugs, and that have subsequently earned tens of billions of dollars from selling them.
They sent drug representatives to doctors' offices, but there was much more than that. Key opinion leaders in the field of pain all across North America gave talks at CME events, continuing medical education events, at fancy restaurants. I went to them myself and I was told that not only should I use these drugs, but also that if I didn't use them, I was being “opiophobic” and was depriving my patients of a proven therapy. The virtues of these drugs were extolled. The companies made their way in some instances—including at my own medical school—into the curriculum where individuals in the pay of the companies that make these drugs taught medical students for years without disclosing their conflicts and gave them overly rosy views of the utility of these drugs.
As I said before, for many of us, this was a message we were quite happy to hear. We now, however, realize with the benefit of hindsight that we should have known better. I can tell you that there are no good studies showing that opioids used in the long term improve patients' outcomes. The overarching goal when I prescribe a drug to a patient is to give more benefits than harms, and there's never ever been a study that shows that in the long term this happens.
Most of the studies, by the way, go for eight or 12 weeks. They involve very carefully selected patients who have no risk factors or as few risk factors for addiction as you can find. They're not on benzodiazepines. They have no mental health problems. They have no history of having had trauma as a child. They show that over a couple of weeks these drugs lower pain scores. The fact that there are no long-term studies didn't stop Health Canada and the FDA from approving these drugs for long-term use, and we've now seen what amounts to a 20-year experiment on the population. We've seen and we know that the beneficial effects of these drugs very often wear off, and increasing the doses doesn't solve this problem; all it does is add to the toxicity. Virtually everyone who takes these drugs daily is dependent on them, making for a self-perpetuating therapy. You can't stop these drugs. Even if the pain-reducing effects have worn off, stopping the drugs will make you sick and it will lead patients to perceive that the drugs are needed. Patients need the drugs just to feel normal.
Critically, we were taught that addiction was a rare consequence of using these drugs long term. I remember hearing these words: less than 1% of patients will become addicted. That's not true. The best estimate at the moment is somewhere in the order of about 10%. Just imagine that: hundreds of thousands of patients in Canada are on these drugs as a result of well-intentioned prescribing, and 10% of them may be spiralling into addiction.
We also know that high doses kill people. I can't tell you how often I see patients coming under my care who are on hundreds of milligrams of morphine or the equivalent. We did a study in 2015 that made it very clear that people on high doses of opioids were more likely to die from their medication than from almost anything else.
When we talk about addiction and death, there's a lot more to it than that. The death toll in Canada, as I'm sure you've already heard, is not known. It sounds as if B.C., with a population of about 4.7 million, is on track for about 700 deaths. That places it up there with Alabama, the worst state in the U.S. in terms of rates.
You can think about it differently. We published a paper in 2014 that looked at deaths in Ontario, and we found that one out of every eight deaths of people aged 25 to 34 involved an opioid. That's a staggering number. When you total the deaths from opioids in Ontario—remember, these are people dying in their twenties and thirties and forties who should have lived to their seventies and eighties and longer—the total years of life lost is somewhere in the order of one-thirteenth of all years lost from all cancers combined.
There are other harms here as well. People driving under the influence of opioids are at risk of collisions. We've shown that convincingly. There are falls. I see older people all the time who are on opioids for chronic pain—often not benefiting, as far as I can tell—who fall and break hips and necks and have head injuries. There is constipation. It sounds like an annoyance. I have had more than one patient die under my care from constipation caused by these drugs.
It might seem counterintuitive, but these drugs can worsen pain. As the doses go up, the pain gets worse because of the drugs. These drugs disrupt sleep. I am convinced they cause depression in some people and cause them to commit suicide, and those suicides are very often blamed on the pain rather than the drugs themselves.
There are other epidemics here like neonatal abstinence syndrome. In Ontario, from 1992 to 2011, the number of babies born dependent on drugs went up 15-fold. That's just from the prescribing. The proliferation of tablets from our well-intentioned prescribing of drugs has left every medicine cabinet in Ontario with some opioids. It's a bit of an exaggeration, but those drugs are there for people who might want to experiment, 16- or 17-year-olds who are curious and find themselves spiralling into addiction.
The epidemic has transformed over the last couple of years, as you've been told. It's not just about OxyContin and Dilaudid, and so on. It's now about fentanyl and heroin. Those drugs have been used for a long time, but a market has been created in response to our well-intentioned prescribing, a market that did not exist to anywhere near the same degree in the early 1990s.
This was a crisis that was largely created by physicians, and it has to do with the fact that opioids, once started, are hard to stop. It was exacerbated in 2012 by the reformulation of OxyContin. Purdue took off their old product, put on a new product that was tamper resistant, and we found a lot of people going to heroin and fentanyl as a result.
This can't be overstated. You can get a kilogram of fentanyl from China for $10,000 or $20,000. It fits in a shoebox and you can turn it into $20 million of profit. That's not ending up, as you've heard, just in heroin. It's ending up in fake OxyContin tablets, cocaine, meth, in fake Xanax tablets.
The scope of the problem in Canada is completely unknown. We know that in the U.S., the CDC estimates that over the last 20 years, about a quarter of a million people have died from opioids, more than half of them from prescription opioids, and about 2.1 million people in the U.S. suffer from addiction. We have no corresponding numbers in Canada. I speculate that somewhere in the order of 20,000 Canadians have died over the last 20 years from these drugs. The fact that no federal politician can tell you that number is a national embarrassment.
This is the greatest drug safety crisis of our time, and it's not hyperbole to say that every one of you knows somebody with an opioid use disorder. Whether you realize it or not, you do, and it's quite possible that you know someone who's lost a loved one to these drugs. Yet the Public Health Agency of Canada has been largely silent on this issue, despite its mandate “to promote and protect the health of Canadians through leadership, partnership, innovation and action in public health”. Go to their website, search fentanyl, and you'll find almost nothing.
Health Canada seems to have largely handed this file to CCSA, which I think is a good organization and has all kinds of potential, but it's not adequately resourced and it's not focused exclusively on opioids. It has alcohol and other drugs under its consideration. It feels very much as if no one is really in charge of this file and everyone is keen to pass the buck to someone else. Only recently we've begun to see some federal leadership on this issue with the hastening of the move of naloxone to non-prescription status; reducing barriers to safe-injection sites, which are very important; and this upcoming summit in November.
To solve this problem, I think the response needs to be collaborative, proportional to the scale of the problem, and urgent.
If 30 or 40 Canadians were dying every week from the Zika virus, your hair would be on fire with the scope of the problem. I mean, this is actually what's happening now. We need timely surveillance, and not just in B.C., which is the only province that is doing it in a timely fashion. We need it everywhere, and not just on deaths but on non-fatal overdoses as well.
Naloxone saves lives, and it should be everywhere. It should be in corner stores and gas stations for free.
Health Canada has good grounds to revisit its decision, its indications, for these drugs. There has never been a study, as I said, that shows that these drugs are safe and effective for chronic pain. I think that the label, the indication, should be revised, and when doctors choose to prescribe these drugs for chronic pain, they should do so off-label, without an official endorsement from our national regulator.
We can give serious thought to removing market approval for the highest-potency drugs out there: the fentanyl patches of up to 75 and 100 micrograms, OxyNEO 80, and the highest formulations of Dilaudid. The provisions under Vanessa's law give the minister the power to do exactly that.
We need to change how doctors prescribe. Doctors need to start these drugs much less readily, and escalate doses much less readily than they have. A whole generation of doctors has lost respect for these drugs. We do not see this as we did 20 years ago.
The education of physicians is important, but it is not going to solve this problem on its own. It has to be detached completely from industry, and from pain specialists who take money from these drug companies.
You'll see new prescribing guidelines for physicians coming out early next year. I'm on the steering committee for that, and I think that will be helpful. However, the fewer patients who start on these drugs the better. The patients who are on very high doses need to be de-escalated cautiously and closely.
We have a large swath of the population with addiction. I think it is very important that we perceive this as a public health problem and not a criminal one. When somebody steals from a pharmacy or holds up a store, it's not because they're a bad person, but a person who needs help.
Many of these people want out. They need rapid access to opioid substitution therapies, like Suboxone. They need access to supports. We need many more clinicians who know how to treat these people, and ready access to them. We need safe injection sites. I think the point has been made that the Respect for Communities Act poses a major barrier to the construction of these sites.
I will leave you with one last point. This is not your usual epidemic. No one has ever argued for more Ebola, more Zika, or more influenza. There are forces at play that will argue that physicians should not prescribe differently, that we need these drugs for chronic pain, which, I think, is exactly the wrong message. Those sorts of oppositional comments need to be disregarded.
I'll leave my comments there.