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Risky repercussions

The crackdown on opioid prescriptions in Canada is pushing people to the street

The crackdown on opioid prescriptions in Canada is pushing some people to the street

Strong painkillers have helped Chris get through the last 30 years.

He was first prescribed Tylenol 3s, a mix of Tylenol and codeine, and at the age of 12 when he started experiencing discomfort from his irritable bowel syndrome. Eventually, he developed Crohn’s disease and his doctor put him on potent opioids like dilaudid, which is used to treat severe physical pain — which he needs in order to do things like get out of bed and walk the dog. They also boost his state of mind.

Chris is now 42, and he admits that his dosage is on the high side: A cocktail of 12 pills that amounts to 8mg each of hydromorphone. But, he says, it’s been working. When he tried to decrease his dosage himself, life became unbearable.

“It’s cruel.”

“It’s like the worst flu you’ve ever had times 10,000,” said Chris, who requested that only his first name be used for privacy reasons. “Your hair hurts.”

But in January, Chris says he was forced into withdrawal after his doctor told him he’d have to start cutting down because his opioid-prescribing doctor was being investigated by the regulatory body for physicians and surgeons in Ontario. Although the doctor didn’t respond to phone calls and messages from VICE News, it appears to be part of the broader effort by Canadian health authorities to crackdown on the amount of opioids being prescribed as a way to curb the overdose crisis that’s resulted in thousands of deaths across the country in recent years.

But it’s measures like this that can cause many patients more harm than good — and even push some, like Chris, to look to the streets for illicit drugs that can fill that void.

He says his dose of dilaudid was cut by a small percentage at first, but then chopped in half in February. That was when he turned to the fentanyl black market to dampen the hellish withdrawal. Chris said he has used illicit drugs recreationally at points throughout his life, but never as a means to function. “He [the doctor] explained his case with the college and so on, and basically they’re threatening his ticket, his license to practice medicine,” said Chris. “It’s thrown my life upside down. Daily discomfort; it’s affecting my quality of life … It’s cruel.”

According to other patients and harm reduction workers who recently spoke with VICE News, Chris is not alone, and they’re raising concerns that cracking down on prescriptions does not treat the root causes of addiction and conflates overprescribing with the contaminated street drugs that are responsible for the vast majority of overdose deaths. They also warn of a dangerous deja vu, as policy makers adopt measures reminiscent of classic war on drugs tactics that triggered the crisis in the first place.

This year, Canadian health experts will publish new national opioid dispensing guidelines for physicians for the first time in seven years. It’s meant to correct decades of indiscriminate prescribing practises that helped turn Canada into the world’s second-largest consumer of opioids after the U.S. The current guidelines, crafted in 2010, recommend that if a patient is being prescribed a dose of 200mg of morphine, they warrant closer monitoring by doctors. That threshold is four times higher than the one found in guidelines published by American health authorities.

Over the last few months, provincial regulatory bodies have been issuing notices to healthcare providers regarding the upcoming changes, which health authorities say include lowering the maximum dosage by about half. On top of that, official investigation proceedings have been launched into doctors who are flagged for questionable or dangerous prescribing practices.

Last October, the College of Physicians and Surgeons of Ontario — the entity that governs physicians in the province — launched an unprecedented investigation into 86 doctors flagged by the Ontario health ministry’s narcotics database for prescribing astounding doses of opioid to patients, including fentanyl and oxycodone. Some doctors were flagged for prescribing the equivalent of 150 Tylenol 3s per day, according to Ontario’s health minister. The Ontario college’s counterpart in Nova Scotia also announced a similar investigation into 10 doctors there.

“I’ve had to go around their laws just to get what I need to feel healthy.”

Due to intense restrictions around confidentiality and privacy, these colleges won’t publicly confirm how many doctors are still under investigation, let alone provide updates on the cases. Ultimate outcomes are made public only if a disciplinary decision or official warning is rendered. Otherwise, it all remains secret.

This all happened around the same time that the Ontario health minister, Eric Hoskins, released a new “opioid strategy” last October that includes striking high-strength prescription opioids from the list of medications covered by the Ontario drug benefit program, which subsidizes drugs for seniors and people who receive social assistance. In other words, the change means very little for those on private insurance plans, or those who can afford to pay for their high-dose opioids out of pocket and who are more likely able to stay on them.

Catherine Hacksel, a drop-in coordinator at the Drug Users Advocacy League in Ottawa, says that slashing prescriptions and de-listing them without simultaneously boosting addictions treatment and mental health supports is a recipe for chaos. She added she would like to see a more consistent approach among doctors who try to lower their patients’ dosage.

“We have a health care system that, when it comes to drug use and addiction, it doesn’t foster productive outcomes,” said Hacksel. “People get prescriptions without doctors properly assessing things like their mental health and trauma issues, and then they are penalized or cut off for having opioid dependence without being given any alternatives.”

Hacksel added that most mental health treatments and addictions counselling in the area have long wait lists, which means that when doctors go about reducing opioid prescriptions, many patients have nowhere to go or get stuck in limbo.

“For the most part, there’s such a limited relationship people have with their doctor, and they don’t get a realistic sense of your mental health, housing, work, relationships. Things that are relevant to addiction,” she explained.

“This is the situation I’ve been put in.”

So Hacksel’s program helps equip people like Chris with naloxone kits and other harm reduction tools to ensure they don’t overdose and die when using.

“This is the situation I’ve been put in,” said Chris, who said his medication was cut further this month. “But I also know that my doctor is being put in a situation he doesn’t want to be in either. We are all being forced to do things we maybe don’t want to.”

Similar scenarios are playing out in Toronto. Last month, the city’s Medical Officer of Health released its overdose action plan, which specifically recommends that the board of health consult with people who use drugs and other experts before changes are made to the availability of pharmaceutical drugs, such as delisting opioids from provincial drug plans, “to ensure new regulations do not force people into illicit markets.” It also calls for the board to consult with people who use drugs to create “protocols for healthcare providers for prescribing and tapering patients off of opioids that allow for a range of patient needs,” including developing individual drug transition plans.

For the last 10 years, Jim Meeks has been on a high-dose of prescription opioids, including fentanyl patches. Meeks, 66, is a harm reduction worker in the city who was homeless and using drugs on the street due to issues with pain in his spine. He was prescribed fentanyl in 2006 after having surgery, which was covered by the Ontario drug benefit plan and his insurance policy at work. Since then, the prescription has helped him stay in a job and maintain control over his life. He says he hasn’t used heroin or other street drugs in a decade.

Meeks says that’s going to change now after his doctor got a letter from the provincial regulatory body about the upcoming guidelines, and slashed his dosage.

The difference in dosage means that pain has become unbearable for Meeks and he’s taking time off work. His voice cracks as he talks about resorting to heroin again.

“They don’t leave me any option,” he said. “If I had been allowed to use what helps me, I would have a healthy and long life. Instead I’ve had to go around their laws just to get what I need to feel healthy.”

Kevin Rod, a physician at a pain clinic in northern Toronto, wouldn’t confirm to VICE News that Meeks is his patient for confidentiality reasons, but said that Ontario doctors are having to adjust to the incoming guidelines. “There has been more information coming from the harm that these medications can cause to the patients,” he says.

“It’s not only related to patients who abuse the narcotics, even the patients who legitimately use this medication can sometimes get issues related to their level of function and accidental overdose.”

Rod added that if any patient of his is considering using illicit substances, that would be against his advisement and he would encourage them to come back for an appointment to discuss it with him.

Leo Beletsky, a drug policy expert at Northeastern University in Boston, Massachusetts says Canada would do well to learn from the mistakes made by American health authorities when it comes to cracking down on opioid prescriptions. If the goal is to limit the amount of opioids being prescribed, guidelines and surveillance tactics will be successful, he says. But not if the ultimate aim is to reduce the number of people who engage in problematic drug use or die from illicit drug overdoses.

“It’s clear from the U.S. experience that these kinds of measures can be more harmful than they are beneficial if they are not accompanied by simultaneous efforts to reduce peoples’ dependence, and addiction to the drugs,” Beletsky says.

“They don’t leave me any option.”

The surge of heroin overdose deaths in the U.S. in recent years has been linked to previous measures to cut down prescription opioids, sending many patients to the streets to fill the void.

He warns against doctors suddenly cutting their patients off of their opioid prescriptions without proper consultation or offers of other addictions treatments — things that are often difficult to find or get immediate access to.

A 2015 analysis by the Centers for Disease control found that people who are addicted to painkillers are 40 percent more likely to become addicted to heroin. The chances of this happening rise when access to legitimate pharmaceutical prescriptions is cut of drastically.

“If you’re diagnosing this problem just as a problem of the drugs, as if the drugs were the source of the addiction and the root cause of the problem, you’re missing the point,” Beletsky continues.

“The last thing you want to do is turn those people out onto the street, because their overdose risk skyrockets as soon as you do that. And the chances of bringing them back into the healthcare fold minimizes.”

Cover: Ben Ruby/Vice illustration

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