Report on The Opioid Epidemic, Senior College colloquium March 22, 2018
Report on The Opioid Epidemic, Senior College colloquium March 22, 2018
Leader: John Yeomans, Reporter: Judith Knelman
Participants: Harvey Moldofsky, Ruth Pike, Harold Atwood, Charles Maurer, John David Stewart, Daphne Maurer, Bibhu Mohanty, Peter Russell, Trevor Lloyd, Judith Knelman
Personal Experiences
Colloquium participants were encouraged to describe their personal experiences with prescription pain-killers. One said she feared that reduced access to prescriptions for opioids would affect her own wellbeing should she need a remedy for extreme pain, as that is the only class of drugs that works for her. She said it would be a mistake not to acknowledge the benefits of opioids used for medical purposes. “It’s easy to get off them once you no longer have the pain.” Others felt that the medical establishment is too eager to offer painkillers. One participant recalled how, during hospitalization for a serious and potentially fatal condition, she was urged to take medications that she neither wanted nor needed. Another, having grown worse rather than better after surgery, suffered what he called collateral damage from three medications that had each been deemed safe but never studied as a combination.
History of Opiates
The group established that the use of pain-killing drugs in England, for both recreation and real physical need, began in the eighteenth century with opium. By the middle of the nineteenth century, morphine, derived from opium, was more widely used. Heroin, which is made out of morphine, became popular in the mid-twentieth century, and after it the fentanyl patch to treat severe chronic pain. “People were being pushed into it,” a doctor in the group recalled. “It was a dangerous drug.”
Opioid use and deaths (in 20 years of opioid epidemic)
Late in the twentieth century, scientists trying to find where pain originated determined that it was the result of the brain’s interpretation of sensory or internal signals. Opiates, said a member of the group, produce a state of euphoria as well as reducing pain and anxiety. Unlike cocaine, which can cause stroke or cardiac arrest, opiates are not a stimulant; in fact, the major pitfall of using them illicitly is that they slow down breathing: too much of them can kill.
The entry of what was at first thought to be a miracle painkiller, oxycodone, into the pharmaceutical market in the late 1990s changed the illicit drug market as well. In the 2000s this became the drug of choice for recreational users because it was not only powerful and long-lasting but also widely prescribed. “One of the key points is access to these medications,” a physician in the group pointed out.
Social Consequences and Social Control
In both Canada and the United States, overdoses of powerful opioid drugs obtained through prescriptions and often resold by pushers are killing rapidly increasing numbers of addicts to the point where alarms are regularly raised in the media about the opioid crisis. Opioid use, and deaths due to opioids, have risen by several times since 2000. Despite pressure from health authorities, physicians working in pill mills still prescribe and renew heavy-duty painkillers, addicted patients still go from doctor to doctor seeking more prescriptions, and some patients who don’t really need them score prescriptions that they can then sell. At any point, a user can end up with a dose that contains tainted fentanyl – imported through the mail from China – and become an overdose statistic. The group was told that at one site where a chemist was available to check substances to be injected “a lot of carfentanil was found. That’s what’s used to sedate elephants. People didn’t know what they were taking.”
What can be done to stop this cycle? There are legal as well as clinical ways of dealing with this problem. If doctors are regulated into prescribing inferior alternatives to oxycodone, patients who need the higher-functioning drug will suffer. If drug-dealers are named and punished, illicit drugs will become harder to get and therefore higher-cost. One participant pointed out: “Every time you have increased enforcement, you’re benefitting the pocketbook of the Mafia.”
Said another: “Make changes so the drugs are not illegal. Make them available. Making them illegal isn’t working.”
Treatment options for overdoses and chronic addiction
Participants noted that conquering addiction is a hard, slow, expensive process. Though the colloquium advocated devoting more public money to the treatment of drug addiction, the suggestion was refined to pinpoint mental health problems. “You can’t stop their addiction.” A member of the group noted that even if a rehabilitation centre did stop someone’s addiction, it would very likely return when the setting was changed back to the original one where the damage was done. More efficient clinical interventions are naxolone for overdoses, psychotherapy, and drug therapy with methadone, Buprenorphine and Suboxone to make withdrawal less difficult.
The consequence of addiction is major social upheaval including criminal activity, public disorder, and death. The more expensive an addiction becomes, the more addicts will be motivated to steal to support their cravings. “The problem is going underground,” said one member. The group agreed that social control, including policing and safe injection sites, can lessen the impact of drug use on the community.
Long-term expectations
If more money is put into recovery, will there simply be more relapses? If injection sites are sponsored by public health authorities, will this be interpreted as permission to break the law? One participant suggested that Toronto look to Vancouver for its approach to harm reduction for chronic drug users. Insite, the first legal supervised injection site in North America, is a structured setting that offers needles but not drugs, addiction treatment; first aid, including antidotes to overdoses; and mental health assistance. Maclean’s called it “a kind of centre of excellence for shooting up safely.”
Reading
Opioid use, and deaths due to opioids, have risen by several times since 2000 in the United States and Canada. We will discuss current data on these changes, many possible causes for opioid use and overdose, and different approaches to treatment (abstinence, social control, drug therapies).
Epidemiology: “Opioid epidemic” Wikipedia, 13 pp. + references. “Countermeasures” are discussed in the last 5 pages. https://en.wikipedia.org/wiki/Opioid_epidemic
“Apparent opioid-related deaths in Canada” Government of Canada (Dec. 2017). 15 pp. mainly tables. https://www.canada.ca/en/health-canada/services/substance-abuse
Prescriptions: “Amount of opioids prescribed dropping in Canada; Prescriptions on the rise.” Canada Institute for Health Information, 4 pp. https://www.cihi.ca/en/amount-of-opioids-prescribed-dropping-in-canada-prescriptions-on-the-rise
Pharmaceuticals and pain killers: Keefe, “The family that built an empire of pain.” New Yorker, October 30, 2017. 45 pp on the history of OxyContin, not required. https://www.newyorker.com/magazine/2017/10/30/the-family-that-built-an-empire-of-pain
“Let Cities Open Safe Injection Sites.” New York Times, editorial Sunday Feb. 25, 2018. US and Canadian approaches are compared. https://www.nytimes.com/2018/02/24/opinion/sunday/drugs-safe-injection-sites.html?rref=collection%2Fsectioncollection%2Fopinion-editorials&action=click&contentCollection=editorials®ion=stream&module=stream_unit&version=latest&contentPlacement=40&pgtype=sectionfront
A two page reading from “Pretty Ugly” by Charles & Daphne Maurer
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