Opioid-related deaths in Ontario from prescription narcotics double over the past five years
From the Canadian Medical Association Journal
CMAJ Research Article: Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone
by Irfan A. Dhalla, MD MSc, Muhammad M. Mamdani, PharmD MPH, Marco L.A. Sivilotti, MD MSc, Alex Kopp, BA, Omar Qureshi, MD and David N. Juurlink, MD PhD
Deaths related to the use of prescription opioids - CMAJ Commentary
Opioid deaths skyrocket since 1991: study
December 7, 2009
Doctors may not appreciate how potent OxyContin is, medical toxicologist Dr. David Juurlink says. (Toby Talbot/Associated Press)Drugs like OxyContin are killing users in Ontario at twice the rate they were in 1991, a new study suggests.
The rate of deaths involving narcotic painkillers went from 13.7 per million in 1991 to 27.2 per million in 2004, said Dr. David Juurlink, a medical toxicologist at Sunnybrook Health Sciences Centre in Toronto.
He and his colleagues published their findings in Monday's issue of the Canadian Medical Association Journal.
In particular, deaths from oxycodone, mainly marketed as OxyContin, increased about fivefold after the drug was added to Ontario's formulary, the list of drugs covered by the province's health plan.
The cause of death was deemed unintentional by the coroner in 54.2 per cent of the cases and undetermined in 21.9 per cent.
The researchers looked at prescribing data from IMS Health Canada, which collects information from about two-thirds of Canadian pharmacies, reviewed records from Ontario's chief coroner, and tracked patients' medical visits based on health-care databases.
"The frequency of visits to a physician and prescriptions for opioids in the month before death suggests a missed opportunity for prevention," the study's authors concluded.
Between 1991 and 2004, 7,099 deaths with complete records were attributed to drugs or alcohol. In 3,406 of these deaths, or 61.9 per cent, opioids were implicated as a cause of death.
"I think what needs to happen is that patients, and probably to a greater extent their doctors, need to develop an appreciation for the toxicity of this drug and probably a respectful fear of using this drug in patients who are prone to misuse or who are prone to consume alcohol or sleeping pills. It's just a bad combination," said Juurlink. "It's a setup for disaster."
On a milligram-for-milligram basis, OxyContin is 50 per cent to 100 per cent more potent than morphine, Juurlink noted.
"I think that many physicians really don't appreciate how potent this drug is," he said. That lack of appreciation can lead to complacency on the part of doctors prescribing it.
The rise in opioid-related deaths was due in large part to "inadvertent toxicity," or accidental, the study's authors said.
The societal burden of death and disease related to opioids in Canada is "substantial" they said. The annual incidence of opioid-related deaths in 2004, 27.2 per million, was between that of HIV infections at 12 per million and sepsis or blood poisoning at 40 per million.
In a commentary that accompanies the study, Dr. Benedikt Fischer of Simon Fraser University in Burnaby, B.C., and his co-authors noted that as prescription drugs are involved in more overdose deaths than either heroin or cocaine in North America, the profile of those dying may be shifting from marginalized people to more "middle class."
"I didn't choose this," said Phyllis, a woman in London, Ont., who is recovering from an addiction to OxyContin. CBC News is protecting her identity.
"It took me over. I didn't choose this. I didn't want to be addicted. I grew up in a fantastic home with great parents and grandparents."
Phyllis said she experimented with OxyContin to help her deal with problems she was having in her life.
"Well, it didn't really. It made me forget," she said.
Fischer said Ontario is on the higher end for consumption but that the overall picture is likely similar in other provinces.
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Study finds huge rise in oxycodone deaths
CTV.ca News Staff - Dec. 7 2009
Deaths in Ontario from prescription narcotics have doubled in the last five years, fuelled in part by the addition of OxyContin to the province's public drug program, a new study suggests.
The study, led by doctors at St. Michael's Hospital and the Institute for Clinical Evaluative Sciences (ICES) in Toronto, found that deaths from opioid pain relievers soared from 13.7 deaths per million residents in 1991 to 27.2 deaths per million residents in 2004.
And the addition of a long-acting form of oxycodone, called OxyContin, to the province's drug formulary in January 2000 corresponded with a five-fold increase in oxycodone-related deaths. The drug formulary funds medications for seniors, welfare recipients and people with disabilities.
"We were quite surprised by the number of deaths that related to prescription opioids. Towards the end of our study, there were well in excess of 300 deaths each year in Ontario alone," lead author Dr. Irfan Dhalla told CTV News.
The researchers hope the figures will be eye-opening to both patients and doctors, who may not realize just how dangerous these drugs can be.
Dhalla, a doctor and researcher at St. Michael's, says his team conducted the study after noting anecdotally a rise in patients dying from narcotic pain killers, which are among the most commonly prescribed drugs in Canada.
The medications are used to treat people with moderate-to-severe pain but can have fatal side effects, because they can lead to depressed breathing and decreasing level of consciousness.
To determine the scope of the problem, the researchers reviewed nearly 7,100 files at the Office of the Chief Coroner for Ontario. They then linked these files with provincial data on physician visits and medication prescribing.
They also analyzed data from IMS Health Canada, an organization that tracks the sales of prescription drugs, to see how the numbers of prescriptions have been rising in recent years.
They found prescriptions for oxycodone in Ontario rose by more than 850 per cent during the study period -- an increase that was much larger than for any other narcotic pain reliever.
They also noted that after OxyContin was added to the provincial drug plan in 2000, deaths from any opioid increased by 41 per cent over the next five years. In fact, deaths from prescription opioids in Ontario far outnumbered those from heroin.
More potent than morphine
Most of the deaths were accidental, though 23.6 per cent were deemed suicides, while in another 22 per cent, the manner of death was undetermined.
"I think the magnitude of this increase was really surprising to us," said study co-author Dr. David Juurlink, a senior ICES researcher and a staff physician at Sunnybrook Health Sciences Centre.
The study appears in this week's issue of the Canadian Medical Association Journal.
Dhalla notes that many of the narcotic deaths happened to people who had received a prescription for the drug in the month before they died, suggesting that most were using the medication not for recreational use but for legitimate pain relief.
"So most of the deaths we observed were accidental," he said. "Our sense is that most physicians may not appreciate quite how dangerous these drugs are."
He says there appears to be a perception in the medical community that oxycodone is simply a different form of Tylenol 3, whose active ingredient is codeine. In fact, oxycodone is even more potent milligram by milligram than morphine.
"It's a dangerous drug. In the wrong patient or in combination with sleeping drugs or alcohol, this drug can kill people," he says.
Many patients, too, don't fully appreciate the potential danger of opioids, "particularly when they are taken in combination with other sedating drugs or alcohol," Juurlink suspects.
He notes that the manufacturer of OxyContin, Purdue Pharma, promoted it heavily when it was first introduced and that may be why the drug became so popular among physicians.
Two years ago, Purdue and three of its former executives, pleaded guilty to misleading the public about OxyContin's risk of addiction and less subject to abuse than other pain medications. In fact it is highly addictive and can be used by recreational drug users, who have dubbed it "hillbilly heroin."
People who abuse the medication crush the pills and then snort or inject the drug so that its pain-killing properties -- meant to be spread out over 12 hours -- are absorbed all at once.
Last month, Ontario promised new rules to restrict how OxyContin is prescribed. The Health Ministry is considering imposing guidelines to cap the amount of pills that can be dispensed at one time.
The new measures would also include a computer tracking system that would monitor how much of the drug is going out by transmitting every prescription into a provincial database, which will send out an alert if someone tries to fill a prescription for the same drug two days in a row.
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From Canadian Press - Yahoo News
Opioid deaths, most inadvertent, soar since OxyContin hits Canadian market
December 7, 2009 - By Helen Branswell, Medical Reporter, The Canadian Press
TORONTO - Accidental deaths due to use of opioid painkillers in Ontario have soared over the past couple of decades, increasing dramatically after a new long-acting version of the drug oxycodone - sold as OxyContin - hit the market, a new study suggests.
Opioid-related deaths claim more people in Ontario than HIV, with 27 in a million people dying from an opioid-induced overdose in 2004 versus 12 in a million from HIV, the researchers reported Monday in the Canadian Medical Association Journal.
Lead author Dr. Irfan Dhalla said there's been a suspicion among physicians that deaths due to prescription opioid use were on the rise, but this was the first effort to quantify it in Ontario. He admitted the effect was greater than he anticipated.
"When you think about the fact that there are far more people dying from prescription opioids than from HIV, that to me is surprising," said Dhalla, who practises general internal medicine at St. Michael's Hospital in Toronto.
He and others said similar problems, though in some cases caused by other prescription opioids, are probably being experienced in other parts of the country.
The magnitude of the problem is probably worse than the study implies, Dhalla and other addictions researchers said. The way the data were collected, it is unlikely opioid-induced deaths in seniors would have been captured, Dhalla said, adding that despite that, these types of deaths are likely happening in that age group.
And a leading addictions researcher said the situation has worsened since 2004, the end of the period studied by Dhalla and his colleagues.
"We have strong reason to assume that these numbers kept going up in the last five years because our overall consumption of opioids kept increasing in those years," said Benedikt Fischer, interim director at the Centre for Applied Research in Mental Health and Addictions at Simon Fraser University, in Burnaby, B.C.
"We know that. And given that there's a likely association between those things, these deaths are likely higher today than they were in 2004."
Fischer said the work puts on the radar a problem that has gone undetected in Canada until now.
"This has been a sleeper problem for a long time," said Fischer, who wrote a commentary published with the study in the journal.
"We dish these drugs out like there's no tomorrow here in this country."
In fact, Fischer and his commentary co-author, Jurgen Rehm of Toronto's Centre for Addiction and Mental Health (CAMH), noted that on a per capita basis, Canadians take five times more prescription opioids than do residents of the United Kingdom.
Opioids are strong analgesics - a.k.a. painkillers - which bind to receptors in the central nervous system, decreasing perception of pain and increasing pain tolerance. Members of this class of drugs include morphine, heroin, codeine, oxycodone and its slow-release cousin, OxyContin.
The latter, dubbed "hillbilly heroin," has been the source of significant controversy. While its manufacturer, Purdue Pharma, insisted the slow-release feature of the drug would lower the risk of users becoming addicted, users themselves quickly learned they could speed up the kick the pills deliver by simply grinding up or chewing the pill.
"OxyContin is not just another Tylenol No. 3," said Dhalla. "It has higher risks. It's a much, much stronger opioid."
Dhalla and his colleagues examined trends in the prescribing of opioids in Ontario from 1991 to 2007 and went over coroners' reports of deaths in which opioid use was listed for the period between 1991 and 2004.
Over the period, all opioid-related deaths doubled, to 27.2 per million in 2004 from 13.7 per million in 1991. But after OxyContin was added to Ontario's provincial formulary in 2000, deaths involving oxycodone increased fivefold. (In post-mortem toxicology testing, it's not possible to distinguish OxyContin from oxycodone.)
Opioids were implicated in 3,406 deaths. Most appeared to be inadvertent; coroners ruled the deaths were unintentional in 52.4 per cent of the cases. Suicide was listed on only 23.6 per cent of death records.
The vast majority of the people who died had also consumed other substances that depress the nervous system, such as alcohol or sleeping pills.
"It's this combination of a lot of different drugs which is actually leading to the death," said Rehm, a senior scientist at CAMH.
"And we do not know causally (if) it's substance A or B. It's the combination of all of them. And in this combination, unfortunately, oxycodone is having a major effect."
Dhalla said opioids on their own can slow breathing to the point where a person slips into a coma; when combined with alcohol or sleeping pills, that risk is even greater.
"I think the saddest cases are probably where somebody has gotten into a friend's OxyContin or relative's OxyContin and just taken what appears to have been a very small amount just for kicks and then not woken up," he said.
"And we did see some of those cases."
Addressing the problem won't be easy, the experts suggested. That's because the increased use sprang from a push to better control severe and chronic pain - a problem which many clinicians felt was too long ignored.
But the solution to that problem appears to have resulted in what Fischer and Rehm called a "prescription-opioid-rich environment" - opioids in far too many medicine cabinets.
"The question is how to separate the good from the bad and how to go about that," Fischer said.
"This is a very complex problem. And we can't just now pull out the hammer and start hammering at this. Because we'll probably do a lot more collateral damage than we're doing good."