Why are opioids in the news every day? Here's what you need to know...

November 9, 2016

…Seems like every day there is another headline about opioid addiction in the news. In addition to ongoing concerns about oxycodone and fentanyl, now a powerful animal tranquilizer called carfentanil is being mixed with heroin and is responsible for a wave of overdose deaths in the United States. Carfentanil is also in Canada, adding to what is now considered “Canada’s opioid crisis.” Should you be worried about your plan members (and your families)?

Hitting closer to home

With the barrage of current news about carfentanil often in tandem with reports about other opioids—like prescription painkillers such as oxycodone and fentanyl, as well as illegal street drugs like heroin—it may seem like Canada’s issues around opioid abuse have come out of nowhere. However, after years of declining heroin use in the 1990s, heroin and other opioids made a resurgence in the early 2000s.4 Adding to the situation was OxyContin—a brand-name version of the pain medication oxycodone—which quickly became one of the most highly abused drugs.5

Now the opioid crisis is hitting closer to home not only because the drug issues are spreading across Canada, but also because of who is taking opioids. No longer the traditional image of a drug addict, opioid abusers are increasingly coming from all walks of life:

  • The soccer mom (or dad) who started taking OxyContin for back pain and then became addicted
  • Teenagers who steal prescription drugs from their parents’ medicine cabinets and share them with friends (there is now a name for this: skittle parties)
  • And even athletes who take opioids for pain relief after a sports injury and then get hooked

The consensus is that illegal opioids like heroin have always been a problem, but many of today’s addiction issues began with an opioid prescription for pain relief. Although there is always the risk of addiction when taking opioids even for medical reasons, other factors have resulted in today’s escalating illicit use of opioids. Today, people addicted to opioids are from all backgrounds, social classes, and ages, as experts explain, “There’s no immunity to having an opioid addiction” and “these drugs are pervasive in every population, urban and rural, young and old, rich and poor.”6

To assess the risk to your plan members, it’s helpful to understand how the opioid situation in Canada got to the crisis level.

FIRST, HERE'S THE BACKSTORY...

OxyContin was launched in the United States and Canada in 1996.7 It contains oxycodone in a timed-release formula that can be effective for patients who need round-the-clock relief. Although addiction is a critical issue regarding opioid use in the treatment of non-cancer pain, an investigation revealed that the marketing efforts of OxyContin’s manufacturer downplayed the risk.

Doctors began prescribing OxyContin for acute pain relief for various injuries and post-surgery. They also began prescribing it for chronic pain for conditions like arthritis, migraines, and neuralgia (a chronic pain condition that affects the nerve that runs from the face to brain).

Although OxyContin was initially marketed as non-addictive, it produces a heroin-like high and it proved to be highly addictive. In addition to some patients becoming addicted due to prescriptions for pain, soon OxyContin started showing up on the streets where it was crushed, snorted, and injected by those abusing it to get high. Tampering with OxyContin destroys the time-release mechanism so that the user gets the full effects of the oxycodone all at once.

By 2004, the controversy over OxyContin in Canada had become full-blown.
As the situation continued to unfold, many doctors became increasingly concerned about ensuring that opioids are the best choice for their patients and started to worry about OxyContin prescriptions ending up on the streets. As a result, the OxyContin situation culminated into two seemingly contradictory issues: on the one hand, OxyContin was entering the black market and being misused, while on the other hand, many patients’ pain was left untreated as their doctors became increasingly apprehensive about writing opioid prescriptions, and in turn, some patients became fearful of taking opioids.

Misrepresenting the risks of addiction proved costly: On May 10, 2007, the manufacturer of OxyContin along with three company executives “pled guilty to criminal charges of misbranding OxyContin by claiming that it was less addictive and less subject to abuse and diversion than other opioids, and will pay $634 million in fines.”8

Next in 2012, although the United States blocked entry of generic versions of OxyContin into the U.S. market10 when the OxyContin patent ran out, Health Canada approved generic versions of OxyContin in the Canadian market.11 Also, as the OxyContin patent ran out, the manufacturer replaced it with a new tamper-resistant formulation called OxyNEO that Health Canada approved for sale in Canada. Harder to break, crush, or chew, the strategy was that OxyNEO would help reduce the risk of misuse or abuse of OxyContin. However, with OxyContin now off the legitimate market—and as a result, circulation running dry on the black market, addicts then turned to other opioids like heroin—adding to the already alarming heroin situation. Overall, many experts feel that the misuse and abuse of OxyContin is one of the root causes of today’s illicit drug use, acting as the forerunner to other opioid addictions.

FENTANYL TAKES CENTRE STAGE...

Fentanyl—like OxyContin—has an accepted medical application for pain management. It comes in pills, lozenges, throat sprays, and a topical patch that releases low doses slowly over two to three days. However, fentanyl is even more potent than OxyContin and can be 50 to 80 times more powerful than morphine.12 A dose of fentanyl the size of a grain of salt can produce a heroin-like high, a dose the size of two grains of salt is enough to kill a healthy adult.13 For illicit use, fentanyl is cut with powdered sugar, baby powder, or over-the-counter antihistamines or mixed with other drugs like heroin, cocaine, and ecstasy and sometimes disguised as OxyContin. In addition, users scrape out the gel contents of the patch version and then take it orally or smoke it.

WHICH BRINGS US TO TODAY...

Carfentanil is adding to the Canadian opioid crisis. Although carfentanil is a synthetic opioid like oxycodone, fentanyl, and heroin, it is an animal tranquilizer for livestock and elephants with no safe application for humans. It is considered about 100 times more potent than fentanyl, 10,000 times more potent than morphine, and 4,000 times more potent than heroin.15

Needless to say, the risk of overdose is very high; experts warn that inhaling an amount smaller than a snowflake could trigger a fatal overdose.16 Officials suspect that carfentanil has probably been in Canada as long as fentanyl, but only recently has there been successful seizures of carfentanil.

Law enforcement officials suspect that fentanyl and carfentanil are mass-manufactured in China where sellers easily conceal the drugs inside boxes of things like urine testing strips or generic vitamins. In fact, buying fentanyl online and having it shipped is described as easy as ordering a book online.

After leaving China, the drugs make their way up through the United States to Canada. Recently, several states experienced a wave of overdoses and deaths. This June, there was a seizure in Vancouver of a one-kilogram package of carfentanil bound for Calgary—enough to cause approximately 50 million fatal doses.17 In Canada, drug trafficking typically moves from west to east, and now Alberta and Manitoba have also reported carfentanil overdoses. A Canadian official sums up the situation: “I can’t quote numbers but I can say in the last numbers but I can say in the last number of years throughout all provinces there has been an increase, a significant increase [in deaths linked to the drug].”18

THE TRIFECTRA

But why have fentanyl and carfentanil in particular led the situation in the United States to be described as an opioid abuse epidemic, and in Canada as an opioid abuse crisis? Experts explain these opioids are especially concerning because of these three factors:

  • Ease of market entry: online shopping is easy and so is concealing these drugs to get across borders, with some users having fentanyl sent to them in an envelope that looks just like a birthday card.
  • Inexpensive: a half-gram of fentanyl—which is more than enough for a powerful high—goes for about $40 CAD.19 By mixing carfentanil and fentanyl with heroin and other illicit drugs, drug dealers are able to boost profit margins.
  • Highly potent: these drugs are so powerful that now emergency first responders are wearing gloves and masks to protect themselves from accidentally ingesting even a miniscule amount.

TAMING THE CRISIS

Clearly the opioid crisis is complicated, as Health Canada recently stated, “There is no single solution to this devastating problem, but we continue to find strength in numbers as we collaborate with our partners.”20 This mirrors the viewpoint previously conveyed by the Canadian Medical Association: “The unfortunate reality is that no single level of government, no single health provider group and no single sector of our society can resolve this complex crisis on its own.”21 Fortunately, all stakeholders are taking action.

To address the role of prescription drug use in the crisis, here is an overview of some of the initiatives:

  • Physicians: In 2015, the Canadian Medical Association released their policy statement: Harms associated with opioids and other psychoactive prescription drugs, which outlines its recommendations of what should be included in a comprehensive national strategy to combat the harms associated with psychoactive drugs, whether illegal or prescription based. Specifically the policy recommends enhancing optimal prescribing through evidence-based guidance, education, and supports such as clinical guidance, clinical decision support tools, educational programs, expert advice, and supportive models of care, as well as through physician regulation and the development of a Canada-wide system of real-time prescription monitoring programs.22

At the regional level, areas most severely affected by the opioid crisis continue to put a range of measures into place. For instance, regarding prescribing, the College of Physicians and Surgeons of B.C. has issued new mandatory professional standards and guidelines: Safe Prescribing of Drugs with Potential for Misuse/Diversion. This should help improve the issues around opioid prescribing because it doesn’t allow for any discretion—it clearly states what doctors “must” and “must not” do—and doctors are legally bound to follow the guidelines.23

  • Federal government: In the spring, the federal minister of health explained that she has asked Health Canada to look into updating the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-cancer Pain, which has not been updated since 2010.24 In addition, this summer, Health Canada announced an Action Plan on Opioid Abuse, which outlines initiatives aimed at: (1) better informing Canadians about the risks of opioids, (2) supporting better prescribing practices, (3) reducing easy access to unnecessary opioids, (4) supporting better treatment options for patients, and (5) improving the evidence base.25
  • In the U.S.: The new CDC Guideline for Prescribing Opioids for Chronic Pain recently released by the U.S. Centers for Disease Control and Prevention addresses: (1) determining when to initiate or continue opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care, (2) opioid selection, dosage, duration, follow-up, and discontinuation, and (3) assessing risk and addressing harms of opioid use.26
  • Private drug plans: For several years now, GSC has had a Narcotic Pain Medication Policy in place. As a plan member’s narcotics claims approach a set threshold, a GSC pharmacist requests detailed information from the prescribing doctor regarding why the patient needs pain management, what else has been tried, and what additional strategies are being done concurrently.

WE'LL KEEP YOU POSTED

Ironically, although opioids like fentanyl—and now carfentanil—are in the news daily, the media also report that many Canadians still have very little awareness of these drugs and their potentially dangerous effects. It’s important to not only know about the problem—and its many intricate issues—but also to keep up to date as the situation continues to unfold. As we learn more, you’ll be the first to know.

SOURCES:

1, 9 “’Long past time’ to act on Canada’s deadly opioid epidemic ‘This is the greatest drug safety crisis in Canadian history and it is worsening’”, CBC News, Hakique Virani, Rosalind Davis, David Juurlink, Oct 20, 2016. Retrieved October 2016: http://www.cbc.ca/news/canada/edmonton/long-past-time-to-act-on-canada-s-deadly-opioid-epidemic-1.3812594

2, 6 “Ottawa must act quickly on opioid crisis,” The Star, Tara Gomes, September 6, 2016. Retrieved October 2016: https://www.thestar.com/opinion/commentary/2016/09/06/ottawa-must-act-quickly-on-opioid-crisis.html

3 “Opioid overdose deaths continue to rise in Canada despite removal of OxyContin,” CityNews, Faiza Amin, Mar 7, 2016. Retrieved October 2016: http://www.citynews.ca/2016/03/07/opioid-overdose-deaths-continue-to-rise-in-canada-despite-removal-of-oxycontin/

4, 5 The controversy surrounding OxyContin abuse: issues and solutions, United States National Library of Medicines, National Institutes of Health, Sujata S Jayawant, Rajesh Balkrishnan, June 2005. Retrieved October 2016: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1661612/

7, 8 The promotion and marketing of OxyContin: Commercial triumph, public health tragedy, United States National Library of Medicines, National Institutes of Health, Art Van Zee, February, 2009. Retrieved October 2016: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622774/

10, 11 “Federal government reversing its decision to allow generic OxyContin as addictions surge,” National Post, John Ivison, May 14, 2015. Retrieved October 2016: http://news.nationalpost.com/news/canada/federal-government-reversing-its-decision-to-allow-generic-oxycontin-as-addictions-surge

12 What is fentanyl? National Institute of Drug Abuse, June 2016. Retrieved October 2016: https://www.drugabuse.gov/publications/drugfacts/fentanyl Revised June 2016. “Strongest painkillers are also most addictive,” ABC News, Dean Schabner, May 10, 2005. Retrieved October 2016:
http://abcnews.go.com/Health/PainManagement/story?id=711680&page=1

13 “A killer high, How Canada got addicted to fentanyl,” The Globe and Mail, Amber Nracken, August 2016. Retrieved October 2016:
http://www.theglobeandmail.com/news/investigations/a-killer-high-how-canada-got-addicted-tofentanyl/article29570025/

14, 19 “Fentanyl: Revolutionizing Canada’s illicit market for drugs,” The Argus, Editor, September 27, 2016. Retrieved October 2016: http://theargus.ca/news/2016/fentanyl/

15 “What is carfentanil? Deadly street drug is causing mass overdoses in the US,” Global News, Carmen Chai, September 14, 2016. Retrieved October 2016: http://globalnews.ca/news/2939935/what-is-carfentanil-deadly-street-drug-is-causing-mass-overdoses-in-the-us/

16 “Drug linked to Ohio overdoses can kill in doses smaller than a snowflake,” The New York Times, Jack Healy, September 5, 2016. Retrieved October 2016: http://www.nytimes.com/2016/09/06/us/ohio-cincinnati-overdoses-carfentanil-heroin.html?_r=0

17 “Deadly opioid carfentanil bound for Calgary seized in Vancouver, Enough of the drug seized to produce 50M fatal doses,” Dave Dormer, CBC News, August 9, 2016. Retrieved October 2016: http://www.cbc.ca/news/canada/calgary/carfentanil-seized-border-vancouver-calgary-1.3714070

18 “Police intercept deadly opioid carfentanil: ‘50M doses could’ve hit our streets,’” Global News, Erika Tucker, August 10, 2016. Retrieved October 2016: http://globalnews.ca/news/2873243/rcmp-say-theyve-seized-unique-substance-more-lethal-than-fentanyl/

20 Statement from the minister of health on the opioid crisis, Government of Canada, July 27, 2016. Retrieved October 2016: http://news.gc.ca/web/article-en.do?nid=1105179&tp=980

21 CMA confronts opioid addiction crisis “head on,” Canadian Medical Association. Retrieved October 2016: https://www.cma.ca/En/Pages/gc-2015-
cma-confronts-opioid-addiction-crisis.aspx

22 Harms associated with opioids and other psychoactive prescription drugs, Canadian Medical Association, 2015. Retrieved October 2016:
http://policybase.cma.ca/dbtw-wpd/Policypdf/PD15-06.pdf

23 Safe Prescribing of Drugs with Potential for Misuse/Diversion, Canadian Medical Association, June 1, 2016 (revised August 5, 2016). Retrieved October 2016: https://www.cpsbc.ca/files/pdf/PSG-Safe-Prescribing.pdf

24 “Health Canada to explore national plan to deal with opioid abuse,” The Globe and Mail, Karen Howlett Grant Robertson, April 18, 2016. Retrieved October 2016: http://www.theglobeandmail.com/news/national/health-canada-to-explore-national-plan-to-deal-with-opioid-abuse/article29672196/

25 Health Canada’s Action on Opioid Misuse, Health Canada, July 7, 2016. Retrieved October 2016: http://healthycanadians.gc.ca/healthy-living-vie-saine/substance-abuse-toxicomanie/misuse-plan-abus-index-eng.php

26 CDC Guideline for Prescribing Opioids for Chronic Pain, Centers for Disease Control and Prevention, March 18, 2016. Retrieved October 2016:
http://www.cdc.gov/drugoverdose/prescribing/guideline.html