Canada is the world leader in the per capita consumption of prescription opioids, with Saskatchewan and Manitoba leading this country in both addiction and HIV in statistics that have been on the rise for eleven straight years. Canada‘s rate of opioid use increased by 203% between 2000 and 2010, according to the International Narcotics Control Board.
Dr. Lindy Lee examined some of these factors and how physicians and society need to change the way they treat addicts at the 2013 Drug Strategy Conference held at Trailview Alliance Church May 8 and 9.
“I consider myself a free-lancer attached to different areas. For eight years I worked under the Department of Psychiatry, running the addiction unit in the Health Sciences Centre, Winnipeg, so I was a University Department of Psychiatry employee. I’ve worked for about 10 years for the Addiction Foundation of Manitoba, a little bit on the Absence-based program, but mainly as a Methadone physician under contract, and I have a part-time position at the Manitoba College of Physicians and Surgeons around quality care in Methadone.”
Lee says addiction is an equal opportunity illness, and recovery is more than just stopping drugs. The solution involves educating doctors, children and parents - beginning at a grass roots level - about the predictors for opiate abuse and the tragic consequences of addiction.
That education also frequently involves teaching parenting skills and social skills to help young adults avoid risk factors for addiction, and to insist on treatment availability if addiction becomes a problem.
“A perfect storm comes from circumstances where you’ve got soft [physician] prescribers, unhappy kids, easy connecting over the Internet, broken families, and it all comes together.
“It’s about training doctors to be more aware, less naïve, and just challenging all the past education around pain and management, and … that the prescription pad is not the only way to answer that; it’s just a piece of it.”
A sensible person recognizes when they are over-using a particular medication and makes an effort to cut back. Other people faced with anxiety and stress might tell themselves they just need more medication, and their lives becomes increasingly dysfunctional because now they have added the overuse of medication to their challenges.
Fighting addiction begins with understanding the difference between substance dependence and substance abuse.
The standard accepted definition from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition defines Substance dependence, or addiction, as being indicated by the presence of three or more of the criteria listed below in the last 12 months.
· Tolerance: Does the patient tend to need more of the drug over time to get the same effect?
· Withdrawal symptoms: Does the patient experience withdrawal symptoms when he or she does not use the drug?
· Continued use of drug despite harm: Is the patient experiencing physical or psychological harm from the drug?
· Loss of control: Does the patient take the drug in larger amounts, or for longer than planned?
· Attempts to cut down: Has the patient made a conscious, but unsuccessful, effort to reduce his or her drug use?
· Salience: Does the patient spend significant time obtaining or thinking about the drug, or recovering from its effects?
· Reduced involvement: Has the patient given up or reduced his or her involvement in social, occupational or recreational activities due to the drug?
Substance abuse involves an intentional, self-destructive pattern of inappropriate substance use resulting in significant negative consequences, including physical, social, interpersonal and legal.
A lot of people live with mental illness or have endured abuse, trauma and pain in their lives, but never become addicted to drugs. What shifts the balance?
Lee said, “I think some people could say we’re becoming a disconnected, somewhat decadent, detached, troubled society. There’s porn, there’s gambling, everything’s becoming accepted. There’s family dissolution … there’s difficult things happening, and we’re making drugs and alcohol readily available.”
Human history shows a pattern of recurring cycles of substance abuse throughout most societies, but technology has greatly contributed to the current addiction era with the instant transmission of, and unlimited internet access to, information about sourcing, preparing and administering illicit and prescription drugs.
Teens exceptionally vulnerable to addiction
“Their judgment and cognitive abilities have not yet fully developed,” Lee noted, “and also whatever age you start using drugs, we do so much of our emotional growth and developing coping skills during all the stresses of adolescence, setting lifetime goals and where we’re going to go, and from the moment you start using drugs [including alcohol] significantly you block out all that emotional growth, because the drug becomes your coping skill.
“So when you’re 22 and clean up, you have to deal with the social anxiety stuff that someone else dealt with at 13. So you have to catch up financially, educationally, and emotionally.
“That’s why it doesn’t get fixed in three weeks in a rehab program.”
She added, “There are a lot of people that got better, had wonderful support from families, friends who were already in recovery, who were really challenging them and got them involved in AA and NA, did rehab, and they spent a huge amount of time in recovery and they didn’t try going back to school or work for six to nine months, and how much of our life actually pushes us to go right back to school, to work?”
Then there are the genealogical addicts, where three or four generations present concurrent addiction and enabling issues.
“A whole family can become dysfunctional-addicted, and then it’s almost impossible to treat one individual unless they’re wiling to walk away from their family. And then they have nothing. And whole families on Methadone is still chaos.”
Methadone must be used with counseling, Lee cautions, with the goals being to survive, to stop using drugs, and to grow emotionally, followed by weaning. The long-term objective is to get “the best functional life at the lowest possible dose” for the client.
Lee has treated a vast number of addicts, and said the youngest person she had to admit into a Methadone program was just 15. During what Lee described as the Oxycontin epidemic, she treated addicts ranging in age from 17 to 30.
The most recent trend has been adults aged 25 to 60, and some cases are related to the long waiting lists for surgeries, noted Doug Spitzig, the pharmacist manager of the prescription review program, College of Physicians and Surgeons, for Saskatchewan.
“It’s not unusual for a patient to be on these drugs for 18 months before they get their surgery, and they’re hooked before they even get their surgery. Then the surgeon writes a prescription, and there’s no exit plan. They’re turfed out of the hospital as quick as possible.
“I’ve tracked so many patients after surgeries where three years later they’re on the Methadone program.”
The physician’s changing mandate
“What we were taught as young doctors is there’s an obligation to treat pain, whereas now there’s an obligation to treat your patient safely,” Lee said.
The Hipocratic oath ’Do no harm’ has always been the physician’s mandate, but Lee said doctors didn’t realize pain medication could be harmful.
“They were told just the opposite – that you could safely do it, and that you were wrong if you didn’t do it.”
Lee encourages physicians to be proactive when prescribing opiates, and to ask about function, not just pain control.
She also believes a Physician-Client treatment agreement can go a long way towards ensuring safety and trust for everyone involved.
“I will use one doctor, I will use one pharmacy for my meds, I will do urine drug screens, I must make my meds last as they are prescribed, I will not share my medication or sell it.”
Lee acknowledged that treating chronic pain as opposed to acute, short-term pain poses quite a different challenge.
“On my addiction unit I sometimes assess people that other doctors said were addicted, and I get the pain clinic involved and we say no, it’s actually pain and you’re not treating them well enough. And it’s not addiction. But it is a grey area and it often takes time to sort out and it’s often hard to be black and white.”
A complete patient history is a useful tool in establishing the groundwork for a pain management protocol that won’t end up as an addiction or abuse problem.
“I actually take my patient’s life history … and they just lay out first of all the initial ‘difficult life’, and then ‘wow, I’ve spent $30,000 on drugs, wow, I’ve had two criminal charges, two months in jail, two girlfriends have left me, I can’t see my kids, my parents won’t let me in the house, I’ve got Hep. C’ … Just by taking their life history you know they already have addiction because all those consequences are there.”
Lee admits the time and energy required to change physicians’ prescribing patterns is enormous, especially for doctors who are inclined to seek their clients’ approval or are easily manipulated or intimidated by a cunning, determined addict.
“Individuals are playing them. They think, ‘these patients love me.’ More skin and cleavage showing than there should be, or subtle intimidation.”
As part of the education process physicians receive coaching about alternative approaches and therapies.
“You have to meet patient after patient and tell them that you’re changing. It’s really hard to change unless you have to change.”
The results are worth the effort, Lee contends.
“If you work well with the addict, it’s the two of you moving forward together to a better life. It’s a totally different, even wonderful relationship.”
Action by the College of Physicians and Surgeons
The College of Physicians and Surgeons is playing a greater role in addiction prevention through a Prescription Review Program developed by Spitzig that has already saved lives - and the Ministry of Health millions of dollars - by eliminating the duplication of prescriptions.
The goal was to identify problems and find solutions. The mandate was to review for apparent inappropriate prescribing and, or, use of these drugs, and to develop educational programs for physicians.
“We’re not trying to police [addicts]; we’re trying to prevent them from causing harm to themselves or others.
“The monitoring program, which is a bit unique in Canada, is located within the regulatory body [of the College], so it’s an educationally-based program but at the end of the day we still have the hammer of the regulatory body, the licensing body.
“Trust me, if you don’t have that hammer sitting there then you’re not going to get the results.”
Spitzig used a two-pronged entrepreneurial approach.
“Because my background is from the clinical pharmacy, from the trenches, rather than from academia or bureaucracy from the government, I looked at it as if it was my own business. What would I do? And I also wanted to take a look at the drug usage, based on the information they have in their databanks.”
He began with tranquilizers and sleeping pills.
“Those drugs I zeroed right in on and sent letters out to physicians. The first two and a half years, we were able to decrease the number of prescriptions for benzodiazepines in Saskatchewan by 63 per cent. That worked out to probably a $2 to $3 million saving off the drug plan.”
Spitzig also identified five key regions in the province where ‘double doctoring’ was occurring, including Saskatoon, Regina, and between North Battleford and Wilkie, Prince Albert and Shellbrook, and Yorkton and Kamsack.
“I monitor for apparent inappropriate prescribing of the 36 drugs that are all the mood-altering drugs. We don’t go on fishing expeditions. The program is an educationally-based program. It’s looking to red-flag patient complaints, pharmacist concern.”
The criteria for a red flag is a patient who gets a prescription drug from three or more physicians in one calendar month. Then alert letters go out to those three physicians. Last year Spitzig sent 6500 letters for double doctoring, about 600 a month, identifying about 200 individual patients that were double doctoring.
“When I send a physician letters in regards to prescribing, there’s so many of these replies coming back that talk about the [patients’] ‘poor life’ and the ‘poor situation’ these people come from, and there isn’t a single word with regards to a medical indication for prescribing!
“We have a network now with all the law enforcement in the province, so they inform me when their intel says somebody may be trafficking in a prescription drug, so I can intervene with their physician and ensure that they have all the safeguards in place.”
Since November 2006, Spitzig has reviewed about 240,000 patient profiles.
“I didn’t consider myself much of an expert when I first started, but there’s nobody else in the country that has done this.”
The National Initiative: First Do No Harm
It seems fitting that since Canada is leading the world in the per capita consumption of prescription opioids, it should also be a leader in developing a strategy that will chart a course for change.
Spitzig was involved with the development of the 10-year national strategy, launched March 27, 2013, called First Do No Harm: Responding to Canada’s Prescription Drug Crisis, a partnership between the Canadian Centre on Substance Abuse and the National Advisory Council on Prescription Drug Misuse, involving all provinces and territories.
“That national strategy is supposed to take away all privacy issues across the country. It’s saying provinces have to change their privacy legislation for this to happen. That’s going to be 10 years.
“This national strategy is just the start. This is going to be a moving target. The reason it’s 10 years is because you’re looking at changing legislation, societal attitudes, doctors’ education.
“We didn’t get into this problem overnight,” he said, intimating it may take much longer than 10 years to reverse the addiction trend. He added, “I think we’re headed in the right direction.”
“I don’t feel we’re winning yet,” admitted Lee, but conceded, “Perhaps the tide is just starting to turn.”
Events such as the Drug Strategy Conference, local drug task forces, and strategic conversations between parents and youth are fundamental to supporting that turning tide.