ennifer Munroe’s* troubles began with a bad back. “I had sciatic pain — a sharp shooting pain from my back down to my legs,” she says. “And then I started feeling a lot of numbness in my right foot.” Other than that, though, life was good. Jennifer was 31, her daughter was 18 months old, and she and her husband had just bought a new car. They lived in a condo in Burlington, Ont., and were thinking about buying a house.
Professionally, things were good, too. After working her way up in the travel industry, Jennifer had finally landed a management position at a large company. “I’d paid my dues and was finally going somewhere. I had the top sales in the company and so much going for me.” But still her back bothered her.
At first, Jennifer attributed the pain to the hours of sitting required in her job as a travel agent, until a visit to her family doctor revealed she had degenerative disc disease and needed surgery. Jennifer was told she’d have to wait eight months for the procedure, so her doctor prescribed Percocet and OxyContin to help manage her pain in the meantime. The painkillers took care of her back, but also offered her something else: a feeling of invincibility.
“It was such a great feeling, a euphoria,” she says. The overwhelming sense of confidence was something she’d never experienced before. After a lifetime of struggling with low self-esteem, Jennifer says, she suddenly felt important, larger than life. “When I was taking the drugs I was able to be someone I wasn’t — someone I wanted to be.” After only a few months, she found herself hooked on that feeling. “I just kept taking more pills because I never wanted the feeling to go away. And when it started going away, I would take more, and then I would take more.” Though she had no previous history of addiction, even five times her prescribed dosage suddenly wasn’t enough. Eventually, she was taking up to 50 pills a day.
Jennifer’s fledgling family life crumbled. “The pills made me a different person,” she says. “And I did some pretty bad things.” One of those things was cheating on her husband. “I had this medicated confidence that made me feel I could go up to guys and talk to them. I felt like I could get anyone I wanted.” But what her addiction did to her ability to parent is still something she can’t bring herself to talk about. Jennifer remembers being very happy to be a mother before her drug abuse took hold, but once she became addicted, she says she put her daughter’s health and welfare in jeopardy. Eventually, her daughter was taken away from her, placed first in foster care, then with her estranged husband. All the years of hard work slipped through Jennifer’s fingers, too. She was demoted after getting caught taking pills at the office. A few months later, she was let go. “I lost everything.”
Prescription-pill abuse is on the rise in Canada. The situation has become so serious that many health experts, including the College of Physicians and Surgeons of Ontario (CPSO), say it is a public health crisis. North Americans are the world’s most enthusiastic consumers of prescription narcotics, and Canada is second only to the U.S. in terms of overall per capita prescription-pill consumption annually. We’re also the second-largest per capita consumer of opioid painkillers in the world, according to the International Narcotics Control Board.
A class of synthetic narcotics that behave similarly to heroin, opioids include codeine, morphine, hydromorphone, fentanyl and oxycodone. Seventeen percent of Canadians have used an opioid pain reliever to treat some form of discomfort in the last year. And one of the unintended consequences has been an increase in the incidence of abuse. Part of the problem is the nature of the drugs themselves, says Susan Blank, an addiction psychiatrist and chief medical officer at the Atlanta Healing Center.
“Opioids act on a specific pleasure system of the brain, which is the reward system,” she says. They flood this primitive area of the brain with dopamine, causing a feeling of euphoria — great for resolving acute pain, but tricky for long-term use. “People aren’t chowing down on their birth control pills, and that’s because birth control medication doesn’t attach to receptor sites in the pleasure centre of the brain,” says Blank.
Despite all of this, the past two decades have seen Canadian doctors prescribing opioids to patients in record numbers, and for chronic conditions instead of their original intended purpose: the relief of acute, terminal or cancer-related pain. A new study in Canadian Family Physician shows high-dose opioid prescribing increased by 23 percent in Canada between 2006 and 2011, despite clinical guidelines recommending that most patients should avoid high doses of these drugs.
The Pill Problem
Why are so many doctors prescribing opioids for conditions they wouldn’t have treated this way 25 years ago? “I think we’ve been misled, not only about the risks of addiction and overdose but also about how well opioids work,” says Irfan Dhalla, an assistant professor of medicine at the University of Toronto. “We’re now learning that opioids don’t work nearly as well as we were told a decade ago. For instance, they’re simply not as effective for the treatment of chronic non-cancer pain as they are for the treatment of acute pain.” Dhalla also cites a 2013 review that determined opioids are no more effective for treating lower-back pain than analgesics, which don’t come with the added risk of addiction.
Dhalla says that risk is also much higher than doctors previously thought, and their tendency to prescribe freely is partly responsible for the jump in the number of people seeking treatment for addiction to prescription narcotics. The proportion of patients admitted to the Medical Withdrawal Service at the Centre for Addiction and Mental Health in Toronto because of OxyContin dependency increased from 3.8 percent in 2000 to 55.4 percent in 2004. There has also been a marked increase in the number of deaths due to overdose. Researchers at the Institute for Clinical Evaluative Sciences and St. Michael’s Hospital in Toronto found the number of opioid-related deaths doubled in Ontario (to roughly 550 deaths a year) between 1991 and 2010.
While some people came by their fatal doses on the street, a greater number got their drugs directly from a doctor. Health records showed that more than half had visited a doctor in the month before their death and had filled a recent prescription for an opioid. Jennifer says she never had any problems getting her prescriptions filled. “I’d go into my doctor’s office and give any excuse in the book,” she says. She’d also go from walk-in clinic to walk-in-clinic, telling doctors she’d lost her prescription, which was largely covered by social assistance. Jennifer says this went on for a couple of years, and pretty successfully, too. No one caught on because she had a legitimate condition. “I had a letter saying that I had degenerative disc disease, so no one ever questioned me.”
Dr. Rocco Gerace, registrar of CPSO, agrees that some doctors may be too permissive when it comes to writing prescriptions, but he doesn’t believe that those who manipulate the system or indulge in criminal acts should escape culpability. “As the value of these drugs increased on the street, there was a lot of effort by those who would take advantage of that to secure the drugs in an inappropriate way.”
It’s true you don’t need a prescription to get many prescription pain medications; you just need to know someone who’s willing to sell you some. In addition to street dealers, some patients, like Jennifer, engage in “double doctoring,” taking advantage of a lax monitoring system and collecting prescriptions from more than one doctor — some even sell their prescriptions for profit. Before it was discontinued in 2012, OxyContin, a long-lasting variant of oxycodone, was so commonly trafficked on the street that it surpassed heroin in popularity.
More worrisome, the drugs are finding their way into high schools. One-fifth of Ontario students from grades 7 to 12 admitted they’d taken an opioid or other prescription drug for recreational purposes. That’s how Nova Scotia native Sarah Brown found herself hooked on the painkiller Dilaudid at 17. Sarah took her first Dilaudid for fun — she got the pill from her boyfriend, who also used recreationally. The pills came from someone who was selling a prescription, a practice Sarah says is common in her experience.
But what began as a fun thing to do with friends turned into a full-blown addiction that had her snorting pills for a quick high before school. Years passed in a Dilaudid-induced fog, until one day she had a moment of clarity. “I thought, ‘I want things in life. I want a job, I want a family.’ I realized I couldn’t see myself doing that while being strung out on drugs, so that was my wake-up call.” Confused and embarrassed about her addiction, she didn’t know where to turn.
“I was trying to find solutions to see where I could get help while keeping it a secret . . . and get better without my father, mother and work knowing,” she says. Sarah ventured into a local walk-in clinic. “You can go there if you have a cold, but they also have chronic-pain patients and people who are addicted to pain pills and need methadone.” She took methadone for a year, then slowly weaned herself off of it. Now 28 and the mother of a six-year-old, Sarah is baffled by her former life. “I liked the feeling I had at the time. But now that I look back on it, I can’t see myself doing it ever again. I can’t even see what it was about it that I liked so much.”
Because prescription-pill abuse is such a unique, multi-faceted epidemic, it will take a united approach from the health care community, law enforcement, government agencies and the public to solve the problem, says Gerace. In its 2010 report Avoiding Abuse, CPSO made 31 recommendations for addressing the epidemic of prescription-drug abuse.
At the top of the list: Increase pain-treatment education for doctors. Medical students receive on average 16 hours of pain-treatment training — an amount most now believe is insufficient. To augment the skill set of practising physicians, the medical community issued The Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain, a new national guideline physicians can use as a resource when treating non-cancer-related chronic pain. Gerace is encouraged by the new guideline. “It gives doctors a framework. If they’re prescribing too much, it gives recommended limits about how much is appropriate.”
Pharmaceutical companies are also being asked to contribute to prevention measures. In 2012, Purdue Pharma, the makers of OxyContin, released OxyNeo, a tamper-proof variant of the opioid that can’t be crushed, injected or snorted. Recently Health Canada made it clear it intends to broaden this approach, demanding that all makers of opioids ensure their drugs are tamper-proof. Many groups, including CPSO, want to see a more comprehensive approach to relieving chronic pain in Canada — one that doesn’t consist solely of dispensing prescriptions but includes making alternative therapies, such as physiotherapy, freely accessible to patients, as well as seeking contributions from other health care practitioners. “Different health care professionals have different contributions to make to the treatment of chronic pain,” says Gerace. “We should all be working together.”
There are many non-addictive drug therapies for chronic pain, Blank adds. She says the anti-convulsant Gabapentin works for burning and stabbing pain, and some antidepressants are also helpful. “Medications like Aspirin and Motrin can be used in a topical form and put directly on the place where you hurt.” Additionally, there are procedures such as nerve blocks and trigger-point injections that can alleviate discomfort. Most health care workers agree that public awareness about the dangers of prescription-pill abuse is crucial. The main thing parents can do to ensure teens don’t get their hands on these pills is to return unused prescriptions. “One of the problems is people keep these drugs in their medicine cabinets and kids get a hold of them,” says Blank. She also feels that the public could benefit from taking a more critical view of pharmaceutical marketing. “It says we shouldn’t feel pain, or be depressed or be constipated — you shouldn’t feel anything you don’t want to feel, so here’s the pill and here’s the name and ask your doctor. ”
The wake-up call
Eventually, Jennifer’s prescriptions and double doctoring couldn’t keep pace with her growing appetite for getting high. Soon she was supplementing with illicit drugs, which she sought out after an acquaintance told her that mixing prescription pills with crack and cocaine could increase her high. He also told her where she could get them. “It was so easy. You made one phone call and it was delivered.” Jennifer’s friends and family were replaced by other users and dealers. “It changes you. You cut off all the good people, and suddenly you’re just hanging around drug users.” A typical day would find her doing anything she could to come up with the $100 she needed daily to buy crack and cocaine. She shoplifted and then returned the items for money. At times, she resorted to offering sex in exchange for pills. “I had to do things for drugs,” she says tearfully.
Jennifer spent five years in a drug-induced haze. Physically, she deteriorated. “I was a skeleton,” she says. One bender went on for a week. “I was shooting up OxyContin and crack, and one day I shot vinegar in my vein. I’d been awake for five or seven days. I don’t even remember. It’s all very blurry. I had a high fever.” Eventually, Jennifer overdosed and suffered a stroke at home. Unfortunately, her home had become a party place for other users, and it was two days before anyone thought to call an ambulance. Jennifer doesn’t remember much about the days leading up to her stroke, except the sensation of feeling unwell in strange locations.
“I remember not feeling well in the back of someone’s car. I remember being dropped off at a house and being stuck there and being really, really sick. I have just bits of memory here and there and then I don’t remember anything at all.” She does remember waking up in hospital, however, and being told how desperately ill she was. But things still got worse. A subsequent infection related to her drug use coupled with an infection she contracted in hospital attacked her heart and left her in a coma for four months. Her family was told her chances of survival were slim. Jennifer was given last rites. To save her life, doctors performed open-heart surgery, giving her a pacemaker and two artificial heart valves. Incredibly, Jennifer left the hospital with a morphine patch and a renewable prescription. The cycle began again.
Two years later, Jennifer hit another low point. Her mother had just died of cancer, she was living on Ontario Disability Support, and she was miserably addicted to the morphine patch. Then she got a jolt from her family doctor. After Jennifer went in to get her morphine scrip filled yet again, her doctor sent her home empty-handed. “She fired me as a patient,” she says, adding that her doctor told her she believed Jennifer was abusing her prescription, and she would no longer treat her. Jennifer’s first move was to find another doctor to give her a prescription. She went to a pain clinic and begged the doctor to give her a scrip. He refused. Instead, he gave her the name of a local rehab facility. Jennifer had no choice but to seek treatment, and she visited the facility within a few days. “I was tired of living like that,” she says. “I was all over the place, mentally.” Still, she says, getting treatment was one of the hardest things she’s ever done.
Clean since March 2011 and continuing her treatment at a local methadone clinic, Jennifer, now 42, is still in physical pain but is stoic about it. “I just have to deal with it,” she says. “I got a gym membership and work out whenever I can find the time, and I’m on a list to start meditation at the methadone clinic.” The greater struggle lies in repairing her relationship with her daughter. “She feels as though I abandoned her. But I’m a different person today, living life on life’s terms, so my relationship with my daughter is filled with love. However, she just turned 13, and I’m dealing with what every mother out there with a teenager is going through — but the difference is now I’m able to make the right decisions with a clear mind.”
Last September, Jennifer finally went back to work part-time. “It feels so good just being a member of society again. I feel like I have my dignity back.” And rejoining the world has had some other positive effects. “Going back to work got me off my antidepressants.” Rebuilding her life, Jennifer has walked away from her ordeal with a pacemaker and a conflicted perspective on the darkest days of her addiction. “It makes me a little sick thinking about it, really, because I’m not that person today. I wasn’t raised like that. I had a wonderful childhood. I came from a middle-class family, had everything I wanted when I was growing up, and I went to college.” Jennifer urges people to be more vigorous advocates for their own health, and not to underestimate the power contained in one little pill. “You never think it’s going to happen to you,” she says. “Now, my hope for the future is just to live a pain-free, drug-free life.”
*Name has been changed.