Winnipeg Free Press - PRINT EDITION
Prescription for disaster
Misuse use of legal drugs manifests in stealing, addiction, even death
The absolute worst thing, Jerry admitted, was stealing painkillers from the terminally ill.
He lived in a small town in southern Manitoba, so it wasn't hard to find a cancer patient. He'd scope their house, like a thief, and wait for them to leave -- if they could.
"It's very sick and twisted," the 29-year-old confessed.
Wait. You'd steal drugs from people who were dying? Who needed that medication to ease their pain?
Jerry didn't blink.
"No problem," he said. "There's no end to what you'll do as an addict. The things I've done... it's crazy."
Jerry isn't a common thief. At least, he wasn't until undergoing hip surgery a few years back. Doctors gave him Percocet at first, and it worked like a seducing charm. Soon he was gobbling hydromorphone pills.
"It was a better buzz," he said.
His doctor got wise to Jerry's addiction and refused to up his dosage. Didn't matter. Jerry adapted, finding friends or acquaintances -- or even strangers he'd met in a bar -- and piggyback off their prescriptions.
In desperate times, he'd stalk delivery trucks parked in front of pharmacies.
Thirty seconds, in and out. He'd shake the boxes and grab the ones that "sounded like pills."
"Eventually, the drugs took over my life," he said. "I was pretty much a walking dead for three years."
Jerry represents the changing face of addiction in North America. He also symbolizes the dark side of a society that is gobbling up prescription drugs at what many experts believe are alarming rates.
Painkillers. Antidepressants. Anti-anxiety medications. Sleeping pills. Sedatives.
Pills, pills, pills. All are addictive. If abused and mixed together, or combined with alcohol, they can be lethal.
Welcome to the 21st century, where mood-altering drugs no longer need to be procured through illegal transactions in back alleys. You don't need a dealer. You need a doctor. And most of these medications -- unlike cocaine and marijuana -- are not only readily available from your friendly professional, white-coated pharmacist, but marketed through TV ads streaming into Canada from the United States, where the proliferation of prescription-drug misuse is No. 1 with a tablet.
This is not about OxyContin addiction on Main Street. This is about everyday folks trying to get by on less.
Teachers dealing with stress.
A college student fretting about finals.
A workaholic trying to get a good night's sleep.
Or a construction worker dealing with chronic pain just to make it through another shift.
"This type of abuse is not something we've seen before," said Deborah Cumming, national priority adviser at the Canadian Centre on Substance Abuse in Ottawa. "It's really changing how we understand what substance abuse and misuse is. It's pervasive across all social classes and all demographics.
"People are usually associating substance abusers or people with addiction issues as someone using a dirty needle on the street, using heroin. This is very different because the sources are therapeutically legitimate medications coming through the health system, for the most part.
"And we still need these medications to treat chronic and acute pain. That just complicates things even further."
Just ask the health professionals on the front lines, the pharmacists, who over the last decade have seen the prescriptions for painkillers, sleeping pills and pills for anxiety and stress fly across their counters.
"Definitely, you'd be surprised," replied Christian Onyebuchi, a pharmacist from Transcona, when asked if the number of such prescriptions has risen noticeably over the last decade.
"You go into the doctor's office now and say you're tired or feeling down, and they'll prescribe an antidepressant for you. Doctors have pills for every little thing.
"People just can't handle stress anymore. People want things as easy as possible. The world is changing."
Another young pharmacist working at a large chain didn't want to be named but said, "I'm surprised, being a new grad, just how many people take these drugs. I knew people took them. I just didn't know there were that many."
Thomas Ling, who runs his own pharmacy on Henderson Highway, cites societal changes such as an aging population and economic stress. And notably the invasion of television ads for pharmaceutical drugs from the U.S. that stream across the border as easily as episodes of the Big Bang Theory.
"They give you the impression (prescription drugs) are a magical fix," Ling said.
Ironically, there is no magical fix for prescription-drug misuse, a complex, multi-dimensional issue that is now beginning to manifest itself in a range of unsettling consequences from the worst (death) to the dangerous (kids stealing prescription drugs from their parents' medicine cabinets) to the desperate (stealing pain medication from the terminally ill).
First, some numbers. According to the Canadian Institute for Health Information, this country's total expenditure on prescribed and non-prescribed drugs rose 4.8 per cent from 2009 to 2010 to total $31.1 billion. That represents an actual decrease from an average annual growth rate of 8.9 per cent between 2000 and 2005.
Meanwhile, the amount Manitoba Health spent on prescription medications rose from $232 per person to $525, according to the Manitoba Centre for Health Care Policy, 2010.
Of course, those medications include everything from treating hypertension to diabetes. If prescribed and consumed properly, they most often work to various degrees. Prescription drugs not only can vastly improve quality of life, they can save lives, too.
"Imagine a world where we didn't have access to painkillers?," offered Susan Ulan, senior medical adviser to the College of Physicians in Alberta and co-chairwoman of the province's Coalition on Prescription Drug Misuse.
"It doesn't mean we stop prescribing those medications just because a small number of people can run into problems with it. It's all about balance."
As a family physician, however, Ulan sees first-hand the increasing tendency for patients suffering from pain, stress, anxiety or sleep disorders to seek medication in the form of prescription drugs.
"From a human-nature point of view, it's easier for a person to take a tablet than actually make lifestyle changes," she noted. "Because lifestyle changes take a lot more effort. It's human nature to find the quickest, easiest way to solve a problem. But that doesn't work very well when you're dealing with chronic pain or addiction."
Dr. James Bolton, an assistant professor of psychiatry at the University of Manitoba -- whose most recent study of anxiety medication use in Manitoba appeared in the April issue of the Canadian Journal of Psychiatry -- agreed, noting, "Medications for emotional and stressful problems, it's a huge industry and they're very commonly used. We certainly see people who are not on just one medication, but several.
"There's a lot of things we need to consider when we're using these prescription medications," Bolton added. "The tendency to just reach for them has become quite routine. And we're not thinking about all these factors. I'll be the first one to say that as a psychiatrist, I use these medications to treat my patients. So they are important. The problem is when they get used for the wrong reasons or misused. These medications contain a whole range of side-effects, and there's a substantial cost to the health-care system and taxpayers. So we need to be mindful with every prescription we write.
"Nobody's trying to do the wrong thing here. Doctors are just trying to help out. And patients have an honest problem they need help with. It's just so easy to write that prescription. There's a variety of ways that you can tackle insomnia or treat anxiety or depression. But the fastest one is to write a prescription.
"As a result, the other ways of handling things get neglected. As a result, you get on these medications. And the thing about these medications is that you can be on them for years."
Just ask the aforementioned Jerry. But while painkillers such as hydromorphine represent the most dangerous and addictive prescription drugs, experts contend any opioid, psychotic medications (lorazepam/benzodiazepine) or sleeping pills (zopiclone) have their own pharmaceutical baggage -- not the least of which are wide ranges of unwanted side-effects and addiction.
Yet between 2003 and 2007, the use of zopiclone, a sedative prescribed for insomnia, rose almost 50 per cent. In 2010, Canadian pharmacies dispensed seven million prescriptions for sleeping pills, according to IMS Brogan, a private company that monitors the pharmaceutical industry. The majority, some 60 per cent, were written for women.
Zopiclone can be used as an alcohol "enhancer" (a word uses a Winnipeg physician uses). The bad news: The mixture of zopiclone and alcohol can be deadly. In fact, it can be a method of suicide.
Since it's not uncommon for people addicted to painkillers to supplement their self-prescribed dosages with alcohol or sleeping pills, the results -- according to more and more statistical data in North America -- are lethal.
In Ontario, for example, the coroner's reports indicate the number of opioid-related deaths increased by 49 per cent from 2002 to 2006.
"We have a lot of dead people related to the misuse of drugs," said Dr. Benedikt Fischer, a Simon Fraser University professor who directs SFU's Centre for Applied Research in Mental Health and Addiction.
"We think that in Canada probably half of all overdose deaths involve prescription opioids."
Fischer concedes statistics linking prescription drug misuse to mortality rates in Canada are "more fuzzy." But he added: "That's a data problem we need to urgently fix to get a clear idea about the exact harm and impact there is. But there's a good enough indication at this point that it's pretty sizable."
Just last week, the U.S. government reported for the first time in the county's history the No. 1 cause of accidental deaths was prescription drugs -- eclipsing car accidents and gunshots.
Prescription-drug abuse now accounts for more overdoses than heroin and cocaine combined, according to the U.S. Centers for Disease Control and Prevention. Of the 37,000 people who died of a drug overdose in 2009, roughly 40 per cent -- more than 15,000 -- were using prescription opiates.
In 2000, American retail pharmacies dispensed 174 million prescriptions for opiates; by 2009 that figure had climbed to 257 million, an increase of 48 per cent in less than a decade.
Canadians aren't far behind. This country is the second-largest consumer of prescription opioids, according to the International Narcotics Control Board (2010). According to IMS Brogan, Canadian pharmacies filled just over 17 million prescriptions for opioids worth about $725 million in 2010.
Not to mention the human cost.
The vast majority of clients who enter the Tamarack Recovery Centre -- a privately run alcohol and drug rehabilitation facility in Winnipeg -- are taking some form of prescription medication, usually in abnormally high quantities.
When Tamarack counsellor Sherry Gable checks the shopping list of meds for clients "sometimes it shocks me."
Yet Tamarack executive director Lisa Cowan points out rehab-centre populations are more likely representing a larger societal problem.
"But we don't hear about it because they don't come to treatment, like the banker who has a bottle of pills in his drawer. And if they are presenting reasonably well to their physicians, nothing will change. They don't ask for help, and if they do it's so much behind closed doors. If people are still managing to get up and go to work and manage their lives, it's a lot harder to say there's a problem."
After all, many people who prescribe to antidepressants or anti-anxiety medications, or sleeping pills or painkillers, don't advertise their prescription-drug use. Not even to their family doctor.
In fact, in a recent U.S. study that involved the analysis of 76,000 urine samples submitted last year, 63 per cent of people on prescription drugs strayed from doctor's orders or sought out pills that weren't intended for them at all. The Quest Diagnostics study found most of the drugs found were painkillers, sedatives or amphetamines.
Translation: Patients will hide their real prescription-drug use even from their own family doctor.
Which is why Cowan believes the number of everyday, functional, suburban Canadians ingesting some form of mood-altering prescription medication is much higher than estimates suggest.
"I have no idea of the exact numbers, but I would not be surprised if one of every two people might be doing that," she said. "I think it's too easy to get a prescription instead of taking a real good look at what's going on with you. People do it all the time because it's a fast-paced world we live in. We run the risk of neglecting what the real issues are.
"We're not handling stress the same way we did 50 years ago. We're almost being conditioned to not like anything that vaguely takes us out of our comfort zone."
Teen Challenge executive director Steve Paulson will display the cabinet containing prescription medications for many of the rehabilitation centre's 30 "students."
"Almost everybody who comes in here is on some sort of feel-good drug," Paulson said. "Something to have them deal with their anxiety. It's so over-prescribed. (The pills) are so easy to get. This is the society we live in. It's off the chain right now."
Take Mark, 21, who has been at Teen Challenge going on 18 months. His mother was a nurse who became hooked on painkillers when he was a baby. She weighed 95 pounds when she died. Mark was seven years old and vowed never to touch drugs.
As a teenager, he was introduced first to marijuana, then Percocet, which he acquired from a friend, who got them from his mother.
"She actually gave them to him to sell," Mark said.
Within a few months, Mark was addicted. What resulted was an endless string of con jobs, fraud and theft -- anything to get drugs. While still in school, Mark and his friends would crush up Percocet pills and smoke weed. They'd get their hands on fentanyl patches, used to treat arthritis and joint pain, cut them into squares, heat them over tinfoil and smoke them like crack.
Mark doesn't believe he's alone.
"People," he said, "are taking lorazepam like it's candy," he noted, referring to the prescription drug "in the Valium family."
Some medical experts are far more cautious about the extent of misuse, however.
"It's hard to say," said Dr. Tamara Buchel, past president of the College of Physicians and Surgeons of Manitoba. "I think if you spoke to most family doctors -- particularly the ones who have a strong relationship with their patients -- I think you would find that it's not very, very wide spread."
Still, finding numbers that precisely reflect the extent of prescription-drug misuse is like trying to quantify the number of people who, say, consume pornography, another multibillion-dollar business -- now accessible in the home at the touch of a button -- that is supposed to exist only in the margins of polite society.
Further, most health-care experts agree the spike in the sale of anti-anxiety and antidepressant medications in particular can be linked directly to the increase in recent years in television advertising that largely features happy people skipping through flowery fields and ends with, "Consult your doctor" and a quickly spouted list of potential side-effects.
It's the pharmaceutical industry's collective answer to "We've got an app for that."
Dr. Joel Lexchin, from the School of Health Policy and Management at York University in Toronto, says there's a phrase for such direct-to-consumer marketing: disease mongering.
The concept is based on mass marketing. For example, Lexchin said most antidepressants wouldn't reap significant profits if they were simply sold to people with a serious condition.
"But there are a lot more people with mild depression than serious depression," he noted. "So drug companies market to people with mild depression because there's a lot more money to be made.
"The drug companies can't do this on their own," Lexchin added. "To some extent, they're feeding off what goes on in the rest of the world. There's economic stress. Factories are closing. People are worried about their jobs. The drug companies are picking up on that."
Another example: A drug called Paxil hit the open market to treat major depression in 1992. Now it's prescribed for everything from obsessive compulsive disorder to what's termed social anxiety, the latter a condition that used to go by another common term.
"Prior to this, we just called it shyness," said Alan Cassels, a drug policy researcher at the University of Victoria and co-author of Selling Sickness: How the Biggest Pharmaceutical Companies are Turning Us All Into Patients.
"That's a classic case of the drug market basically pushing the creation of the disease. So you saw full-page ads and television advertisements for this condition that was said to affect millions of people. They had questionnaires that said, 'Do you like speaking in public?' I mean, most people don't. Or 'Do you sometimes feel nervous at meetings or other social gatherings?' Of course, a lot of people do. That doesn't mean they're ill."
Cassels' research revealed the average American is subjected to 14 prescription-drug ads a day. Canadians, via U.S. television feeds, are exposed to a similar extent.
"My question is, what does that do to the psychological health of the population when you are essentially telling people several times an hour that they could be sick and they need help?" Cassels asked.
Short answer: You push a lot of pharmaceuticals.
"That sort of mentality is fine if you're dealing with computers or laundry detergent," reasoned Lexchin.
"But prescription drugs aren't ordinary consumer items. That's what the advertising is trying to do: turn medications into consumer items. Instead of having patients, you have consumers who are supposed to take control of their own health and go in and demand a prescription.
"It's just a question overall of how we view prescription medications. Do we view them as the same as candy or computers or new shoes? Or do we view them in a different way?"
Added Cassels: "Here's the big problem, in my opinion: Both consumers and physicians are too easily seduced by the promise of a quick fix. That's not to say the drugs don't work in some people because clearly they do. But does everyone who's in a little bit of pain need an opioid? Or does everyone who's experienced some bouts of shyness need an antidepressant called Paxil?
"At one level, it just reflects the crazy society we live in, where we just expect instant food, instant gratification and instant health-care solutions."
SO it’s society’s fault, right? Or those unscrupulous drug companies? Or too many doctors willing to write a prescription and move along to the next patient?
Fischer, for one, doesn't blame the drug makers.
"I'm by no means a defender of the pharmaceutical industry, but that's not the pharmaceutical industry's job," he said. "They are businesses, and they're interested in selling and disseminating as much of their product as they can. The onus here is on the state and governments to properly regulate these drugs. That's a bit like blaming the tobacco industry for the quantity of tobacco use."
But what about the responsibility of patients looking for a quick fix rather than investing -- in some cases -- in the more laborious, time-consuming efforts of lifestyle change?
"Well, I agree to some extent," Fraser replied. "But the onus is on the professionals who provide these pills. Don't forget, you can't just walk in anywhere, to a 7-Eleven, and get these drugs. They're given to people by medical professionals, right? These are the gatekeepers. They're trained, they're paid to give the best medical practice they can.
"They (doctors) are not in the business of harming people. But you have to understand a little of how the medical system works. Doctors are entrepreneurs. In many ways, prescribing a pill to a patient is the easiest and quickest way to deal with a patient's problem rather than going into more in-depth analysis or alternative interventions. It's almost an industrial medical system we've created here.
"The doctor on average has three to five minutes with a patient who comes in and says, 'Oh, my back hurts' or 'I'm feeling stressed out.' Taking the prescription pad and writing a script for a drug that will cure the symptoms for a while is often the easiest and most efficient thing to do, unfortunately. Whether it's the right thing to do is a totally different question."
Still, doctors can't stop patients from lying to them. They can't stop addicts from robbing delivery trucks. They can't stop the endless and increasing volume of patients who are convinced the answer to all their problems -- as seen on TV -- is a little blue or green pill.
"There's no single person or company to blame," Lexchin said. "Everybody has some responsibility in this."
But if the target for blame is not easily identifiable, those who ultimately pay the price for abuse and misuse are identifiable, Lexchin concluded.
"It's dangerous because all drugs have side-effects," he said. "And the reason we take them is because we think the benefits will outweigh the risks. But the milder your condition, the less likely you're going to get any benefit of the drug, but you still have the same risk of having harm."
So what's the prescription? Increasingly, people are dying from misusing legal drugs. An addict is born every day.
Yet pharmaceutical companies are going to keep pushing the next feel-good pill. Doctors won't get any less pressure to prescribe. And the next batch of anxiety-ridden, sleep-deprived, painkiller-seeking consumers will be waiting.
At this rate, all the hydromorphone in North America won't stop the health-care system or law enforcement or society in general from feeling the pain. No quick fixes, either.
"It's a bit of a perfect storm," Cumming said. "We really need to have a comprehensive approach. We've got gaps in all these streams, and we need to start working together. Everybody has a role to play. This is a game-changer for everybody involved.
"Because it's so complex you can't expect just one silver bullet for this. That is the worst thing anyone can expect."
Republished from the Winnipeg Free Press print edition May 12, 2012 J1
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