Health Minister Jane Philpott has called the increase in opioid overdoses a “national health crisis” and says legislative changes are coming soon to Canada. Dr. David Juurlink, head of clinical pharmacology and toxicology at Sunnybrook Health Sciences Centre says “It’s the greatest drug safety crisis of our time, and we must face some unpleasant truths and ask some difficult questions.” We spoke with him at his office to learn more.
CONTEXT: Do you consider this an epidemic?
DR. DAVID JUURLINK: “This is unquestionably an epidemic. It might be the biggest drug safety problem that North America has ever faced. We have more deaths in the U.S. from opioids than we have for HIV. One person every 30 minutes or so dies from the use of these drugs. Anyone who says this is not an epidemic is wrong. There are more now than 100,000 tombstones to suggest otherwise.”
So can you give a medical explanation of how prescription overdose deaths occur?
“The majority of these deaths are people in their 20s, 30s or 40s. These people didn’t intend to die, they were just taking these drugs sometimes as directed by a doctor, often at high doses, and often in combination with other drugs that are depressants, things like alcohol, sedatives, sleeping pills, and they simply didn’t wake up the next morning.
“I have reviewed hundreds of files at the coroner’s office just like this. People who started on these drugs for what seemed like a legitimate reason, liked the pleasurable feeling they imparted, and just continued to use the drugs. The dose escalated and the amount escalated and then they were quickly, you know labeled as abusers and their lives unravelled.
“What happens when someone dies from an opioid is that the drug suppresses the respiratory centre in the brain so the person just begins to breathe more slowly and eventually their breathing stops. That happens particularly in patients who are on high doses of these drugs, or patients who take them in combination with other depressant-type drugs like alcohol or sedatives. For example, drugs that you take for sleep.”
When did this crisis start?
“It has its roots in one main problem and that is that pain is a common thing. Every physician has patients in his or her office with pain and we want to make them better. Patients want to be better. In fact, the relief of suffering is probably the most important thing a physician can do. But in the early 80s if you went to a doctor with lower back pain, a bad knee or something to that effect, you would have probably got a prescription for an anti-inflammatory drug, or maybe cedomediphine. It would be really unusual for you to have been on a prescription for a strong pain killer like an opioid.”
So when did opioids become the answer?
“In the late 80s and in the early 90s there came a push to use opioids more aggressively than we had before, and the messaging that was delivered to doctors was clear. It was that these drugs are stronger than the other alternatives out there, the risk of addiction is very low, less than 1%, you could use these drugs safely in the long term and that if they weren’t working, you could increase the dose with impunity. There was no maximum dose dependent on the patient, and dependent on how long they’d been on the drugs. That push came from a variety of sources. The genesis of it was the pharmaceutical companies that made these drugs, and clearly had an interest in their use, particularly in long-term patients, I mean the market there is huge.
“Doctors got this message and they got it not directly from the companies but often indirectly in the form of experts–experts who would travel around the country and give talks to doctors and say, “Listen, if you’re not prescribing these drugs more readily, you’re doing a disservice to your patient. You’re not being a compassionate physician. You’re opiophobic, and that’s wrong.” So, doctors were actually, I think, quite happy to hear that message because as I said, they frequently had patients in the office with pain. They have very few options to treat the pain, and so the idea that we had this untapped resource that we could use safely, and to benefit our patients, was actually quite appealing. Unfortunately, the experts who imparted that evidence to thousands and thousands of doctors were wrong.”
What kind of evidence?
“They based their opinions on evidence that was terribly flimsy. The doctor in his or her office with a patient in front of them, you know they don’t have the time and the inclination to dig into the literature, they’re just–they want the bottom line. For a very long time we got this bottom line from the companies that made the drugs, from the experts who promoted the use of these drugs and in the process I would add pocketed an awful lot of money, hundreds of thousands or perhaps even millions of dollars. We don’t know yet how much money exchanged hands.
“The other thing that the pharmaceutical companies did was sponsor advocacy groups. These are groups that had, as their mission, putting pain on the radar of hospitals, doctors and the public. I think that’s actually a good thing. Patient advocacy groups are a good idea, but there’s a very fine line between being an advocacy group and being paid. That is, a marketing device for a drug company, especially when you receive large amounts of money from the drug company. These organizations legitimized the notion that we should be using these drugs more than we historically had. That message in hindsight was terribly wrong.”
Have you had a pharmaceutical rep come to your office and try to market a pain killer to you?
“Drug reps know better than to come to my office. I haven’t seen one in a decade.”
What do they say to convince doctors to prescribe them?
“Drug reps have an agenda. Their agenda is to sell their drug. I think reps in the 90s for some of these companies, including Purdue, made huge amounts of money by selling huge amounts of these products. In some instances, by telling doctors things that just weren’t true. They’ve made huge sums of money, they’ve published papers, spoken before tens of thousands of doctors flown all over the country, probably all over the world preaching the gospel of opioids for chronic pain, and it’s all nonsense. You know, if you went to a doctor with a heart attack or cancer and the doctor decided to give you a prescription, you would like to think, and it’s generally the case, that the doctor has some evidence behind what they’re doing, and that there’s some studies that show that the use of this drug will give benefits that outweigh the risks. That has never ever been shown for these drugs in patients with chronic pain. There has never ever been a study of 40-year-olds with lower back pain, or 50-year-olds with osteoarthritis, that shows that these drugs, compared to our older alternatives, are better and safer in the long term.
“Doctors have been led to believe that the data is there. It’s not there. If you unpack the data, it’s all bogus.”
Who is ultimately to blame?
“The pharmaceutical companies that make these drugs deserve a huge share of the blame, but not all of it. The experts who promoted these drugs have a lot of the blame at their feet. In hindsight, how could they have been so stupid as to suggest that taking a drug that is very similar to heroin, and giving it to millions of people, is a good idea? Doctors I think share some of the blame too, and I’m in that group. We were taught that we should use these drugs more readily than we had, and we should not be afraid of the risks of addiction. We bought that. We swallowed that message hook line and sinker. We were glad to hear it because we were tired of seeing people having intestinal bleeding, or kidney failure from the other drugs that they were using and so this message sounded great to us. But it was wrong.”
One of the things I’ve heard from several doctors is that you’re on such a time crunch, so sometimes writing a prescription is quicker. So how do you negotiate between getting a patient out quick enough so you can meet all of your patients in a day, but also treating their pain effectively without just writing a prescription?
“Every patient wants their pain gone or at least minimized, and every doctor wants to do that, but as a society, doctors and patients alike, I think we have this impression that if we have a problem, there’s a pill for the problem. My mood is low, there must be a pill for that. My kid’s not doing well in school there must be a pill for that or I got a bad knee, there must be a pill for that. This isn’t to suggest that pills aren’t sometimes appropriate, but often they’re not, and so the idea that you should go to your doctor with pain, and you should automatically leave with a prescription is flawed. This is so, especially when the drugs come at such a heavy price. All the misery and death that these drugs have caused on the basis of well-intentioned prescribing is a testament to that.”
Do you think that training for doctors about prescription drugs and addiction is sufficient?
“Not even close.
“Not only is training about addiction and drug dependence not sufficient, training on pain is not sufficient. I mean, depending where you went to medical school, you might have only had a couple of hours or lectures about pain, and by the way those lectures might have been delivered by people with very strong ties to the companies that make these drugs. We’ve seen this in Canada with drug company spokespeople and physicians, who are experts in the management of pain, but who have pocketed huge sums of money from the manufacturers teaching in medical schools, and preaching the gospel of opioids. This is a gospel that, as it turns out, is completely incorrect to you, almost a generation now of medical students. We need to unlearn some of the things we were taught and boy is that hard to do.”
“Getting doctors to change their behaviour is difficult. It’s not because doctors are stubborn, it’s just that we are in the habit of prescribing opioids for pain more often than we should. We were taught that it was the right thing to do, and we were taught that if you didn’t do that you weren’t being a caring, sympathetic doctor. It’s all false. I think the most important thing that could happen here is for doctors to use these drugs less frequently than we have, and at doses far lower than we’ve been doing for the last 10 or 15 years. It’s going to take an active appreciation on the part of physicians on the role that they’ve had to play in this epidemic. It’s a hard message to get across.”
And you were saying earlier that pharmaceutical companies shared part of the blame for this. Can you expand on that a little bit?
“I think the pharmaceutical companies have a huge share of the blame at their feet. For example, Purdue Pharma, in the U.S. pled guilty in 2007 for felony of misbranding their drug OxyContin, which has contributed to the deaths of thousands of people over the last 15 years. They told doctors that the risk of addiction was low. They led doctors to believe that this special formulation of the drug, because of how it was made, lent itself to a lower risk of abuse. That’s just nonsense. It didn’t take very long for people to realize that this tablet could be crushed with the back of a credit card and snorted or injected. Again it should have been perfectly foreseeable.”
Can you tell us about the criminal activity of some doctors overprescribing opioids?
“Most prescribing of these drugs is well-intentioned but there are some physicians who are criminals. They are writing prescriptions by the thousands, and they are charging patients for the pleasure of seeing them. They don’t examine the patient, they don’t do anything, they just serve to write the prescriptions for the patient. The patient gets thousands of tablets and just sells them on the street to pay his electric bill. Many people who abuse these drugs buy them on the street, as well. It’s more difficult to catch the doctor who thinks he’s doing good, who’s seeing patients, maybe 60 patients a day and maybe 10 of those have pain, and he writes a prescription for a potent opioid in large amounts. That’s the sort of thing that isn’t supported by any kind of good evidence, but happens all the time across Canada and the U.S. Those prescriptions are often the source of the problem. Either the patient’s abuse them, or they’re selling them to someone on the street.”
If there was one solution that you think would help, what do you think it would be?
“I think the single most important thing is for doctors to dial back on their prescribing in a big way. I think patients need to accept that pain is a part of life. This is not meant to seem unsympathetic, but the idea that we can just extinguish pain with a pill and if we haven’t extinguished it, just increase the dose of that pill is wrong. The most dangerous thing a doctor can do for a patient is try to extinguish their pain by simply escalating the doses of these drugs. So I think if doctors and patients collectively come to the realization that you know these drugs have a place but it’s not every place.
“It’s not every kind of pain that should be managed with these drugs.”
Note: This interview will be part of an upcoming Context program on Opioid Abuse.