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No quick fix to prescription drug abuse

Can science stop the epidemic of addiction to prescription narcotic pills? The answer is a lot more complicated.
Dr. Brian Goldman · CBC ·
Canada is second only to the U.S. in per capita consumption of narcotic painkillers. Addiction and overdose deaths are on the rise - especially among First Nations. Experts were hoping to curb addiction by making narcotics harder to crush and smoke or snort. A  commentary just published in the Canadian Medical Association Journal has a sobering conclusion (apologies for the paywall).

Narcotics - also known as opioid painkillers - are prescribed for people with severe pain.  The trouble is, these pills last three or four hours.  

Beginning in the late 1980s and early 1990s, drug makers began manufacturing extremely powerful narcotic pills that packed twelve hours worth of narcotic into a single pill.  For people with chronic pain, that meant they only had to take a pain pill twice a day.  Very quickly, addicts and recreational users discovered that they could tamper with the pill by chewing, crushing or dissolving it, get the entire 12 hours' worth of narcotic at once, and inject, smoke or snort it to get a heroin-like high.  That's what made OxyContin or Hillbilly Heroin - one of the most frequent and most deadly drugs of abuse. A decade or so ago, drug makers began working on a type of OxyContin pill that could not be crushed or dissolved.  A perfect solution to addicts looking for a high, or so they thought.

Full disclosure: I once had an office practice in which I prescribed narcotics including OxyContin to patients with chronic pain.  As I have discussed before on this web site (the archived blog entries no longer go back to 2008) and elsewhere, I also gave lectures and seminars to physicians that were paid for by Purdue Pharma (the maker of OxyContin and more recently OxyNeo) on managing chronic pain.

The commentary in CMAJ - by doctors at Women's College Hospital and the Dalla Lana School of Public Health in Toronto - says that tamper resistant narcotic pills may deter users who are trying to achieve heroin-like high.  According to drug makers, tamper resistant pills reduced accidental overdoses among people who crush and inject or smoke the narcotic.  Make a drug like OxyContin in tamper-proof pills, and users went looking for other narcotics not made in tamper-proof pills. Since regulators ruled that tamper-resistant pills were new products, drug makers marketed them at a high price that discouraged users from taking them.  

Have they put a stop to narcotic abuse? For a whole bunch of reasons, tamper-proof pills have not solved the narcotic crisis, say the authors of the commentary.  First, if you think addicts always chew, crush or dissolve drugs like OxyContin, you're wrong. Many of them swallow the tamper proof pills intact.  Compared to crushing or chewing, it may take more time to get high. But if you take enough of them, you will.  Second, the fact that OxyContin was tamper proof simply motivated addicts to experiment with other narcotics to get high.  That's one of the main reasons why we've got a growing problem of addiction to another narcotic named fentanyl.  Overdose deaths due to fentanyl are on the rise.  Third, the authors say that in marketing tamper proof narcotics as safer than regular narcotics, they may have left the false impression that tamper proof narcotics are safe - which is misleading.

Prescription drug abuse is a growing public health and safety problem in Canada. In the 2012 Canadian Alcohol and Drug Use Monitoring Survey, approximately 410,000 Canadians reported abusing prescription drugs like opioid pain relievers.  The abuse of prescription drugs in teens and young adults is still going up.  Teens are especially vulnerable because they are still growing and developing.  Despite lots of warnings in the media and elsewhere about the risk of prescription opioids, I still see doctors who prescribe far too many narcotics and far too high a dose to far too many people.

The commentary in CMAJ says it's time to stop believing in what it calls 'gimmicks' like tamper proof pills.  It calls for a comprehensive population wide strategy to combat prescription drug abuse.  That includes preventing the problem by reducing kids' exposure to drugs.  It also means early recognition of teens and adults who show early indications of prescription drug abuse through provincial programs that monitor the prescribing of narcotics.  It also means better access to effective addiction treatment programs.   All that costs a lot of money.  Still, the cost of prescription drug abuse and overdoses is almost incalculable.