Perhaps one of the saddest charts that I have received recently was from the Centers for Disease Control and Prevention. In their weekly Morbidity and Mortality Report (November 21, 2014 / 63(46); 1095), they chart the three most frequent causes of death due to injury: drug poisonings, firearm deaths, and motor vehicle accidents. Although deaths due to firearms and motor vehicle accidents have shown a gradual reduction since 1979, drug poisonings have been increasing at a rapid rate. Drug poisoning is now the leading cause of injury death.
When cross-comparing rates of death, no distinction was made between cause. As well, drug poisoning deaths could include both legal and illegal drugs. Because these categories were broad and included intentional (suicide) and non-intentional deaths, I took a closer look at the data provided in the CDC’s interactive database. I looked specifically at unintentional (non-suicidal) deaths involving narcotics (ICD-10.X42: Accidental poisoning by and exposure to narcotics and psychodysleptics [hallucinogens]) and compared that to deaths from sedative use (ICD-10.X41: Accidental poisoning by and exposure to antiepileptic, sedative-hypnotic, antiparkinsonism).
Death due to accidental poisoning by narcotics (opioids) is troubling. That category, alone, contained 13, 932 people or 4.4 people per 100,000 population and represents about 34 percent of all deaths due to drug poisoning. Death due to sedative poisoning, however, was considerably lower (2,292 people in 2012) and flatter across time. This was also true of alcohol poisoning (2176 people) and poisoning from non-narcotic analgesics (210 people).
This point is made even more clear in a 2014 report by the US National Centers for Health Statistics. They report that opioid analgesics were implicated in more than 40 percent of all drug poisoning deaths in 2011. The majority of those deaths involved natural or semi-synthetic opioids, in particular, morphine, hydrocodone, or oxycodone. Less common were deaths linked to synthetic opioids, such as methadone or fentanyl.
Much of the work I do involves helping people who are struggling with chronic disease and, frequently, intractable pain. In the mid-1990s and 2000s, the use of narcotic painkillers (opioids) was often seen as an important line of defense against pain and became a popular treatment strategy. Although that form of treatment is now viewed as possibly irresponsible practice, it is important to remember that, prior to the 1990s, individuals suffering from intractable cancer or non-cancer pain were often under-treated and not typically prescribed any form of pain medication. This led to the unfortunate situation of many individuals living lives of unnecessary suffering.
This began to change with the acknowledgment of chronic pain as a disease in its own right and the recognition that opioid analgesics were a cost-effective method of reducing impairment among those living with chronic pain. It was argued that the potential negative health risks associated with opioid medications could be reasonably managed as long as these medications were appropriately prescribed and carefully monitored. As well, and within an ethical framework, it was suggested that the under-prescribing of potentially effective medication could be viewed as equally as questionable as over-prescription.
During this time, and within the area of addiction treatment, a shift was also underway from viewing abstinence as the only goal of treatment and toward the goal of harm reduction. That change was prompted by the argument that the majority of harm associated with opioid addiction stemmed from the high-risk lifestyle that was endemic in attempting to gain access to opioids through illegal venues. If one was going to use opioids — for whatever reason – it made sense to reduce those risk factors by allowing those with opioid addictions to receive treatment in either a physician’s office or a specialty clinic. This was not decriminalization per se but more of a movement away from a moral framework and toward a health focus.
Finally, in the 1990s, alternate methods of opioid delivery became available in extended release format including MS Contin (morphine sulfate), Oxycontin (oxycodone) and Zohydro (hydrocodone). Because these medications were developed to offer prolonged opioid availability, they were thought to be of practical benefit to those suffering from intractable pain. The thought at that time was that these medications would be less prone to abuse due to the gradual release of their active ingredient and provide less of a sensation of euphoria typically associated with narcotic addiction.
This combination of increased recognition of chronic pain as a definable disorder, arguments that opioid medication could be effective in treating chronic pain and should not be denied, and changes in opioid delivery led to greater numbers of primary care physicians and specialists recommending opioid medications under specific circumstances.
In fact, the majority of medical guidelines and position papers that emerged during the 1990s and early 2000s, argued strongly that long-term opioid treatment was recommended for individuals suffering from chronic pain even if that pain was viewed as relatively mild. As well, it was suggested that risk for addiction from long-term opioid use was low if that medication was prescribed appropriately and one screened for substance abuse risk-factors.
As a direct consequence, prescriptions for opioid medication – particularly extended release formats – began to increase. In some locales, that increase was exponential. Traditionally, Canada has had the dubious distinction of having the highest rate of oxycodone (Oxycontin) prescriptions per capita in the world. Ontario, in particular, represented the epicenter of oxycodone use with oxycodone prescriptions increasing more than 850 percent from 1991 to 2007.
In 2012, because Ontario was suffering from a oxycodone problem, the Ontario government took the somewhat unusual step of delisting oxycodone from its drug benefit schedule. The drug benefit schedule in Ontario provides no-cost or low-cost prescription medication to people over 65 years old, and those receiving social assistance (welfare) or provincial disability benefits. More simply — the elderly, the poor, and the disabled.
At the same time, the province of Ontario also realized that constraining the availability of oxycodone would have a direct impact on individuals dependent on that medication. To address this, the province moved to increase funding for addiction treatment. Whereas, on paper, the model of addiction treatment looked humane, well considered, and holistic, the reality is that most of the funding for addiction services seems to have been funneled into privately-run methadone clinics.
Yet no expansion of any services for people suffering from chronic pain appears to be in the offering – the whole reason why, in the first place, that opioids were promoted as a potentially effective treatment. Even more ironically, the province of Ontario’s position paper on their new drug strategy toward oxycodone reads like a template of earlier arguments from the 1980s for the best approach to assist individuals with chronic pain. That approach consisted of a mutidisciplinary program, ideally offered in the community, that tried to shift the focus toward non-pharmacological methods of coping with chronic pain with an emphasis on increased functioning through reasonable activity.
Here we are 25 years later. The vast sums of money that have been poured into an unworkable opioid strategy for assisting individuals with chronic pain is now being matched by large sums of money directed toward an equally questionable strategy of reducing opioid use.
Methadone maintenance may help some individuals reduce and eliminate their opioid addiction. But the issue of how best to assist people living with chronic pain still remains unanswered.
- Morbidity and Mortality Report (November 21, 2014 / 63(46); 1095)
- Chen LH, Hedegaard H, Warner M. Drug-poisoning deaths involving opioid analgesics: United States, 1999–2011. NCHS Data Brief, no 166. Hyattsville, MD: National Center for Health Statistics. 2014.
- Jovey, R. D., Ennis, J., Gardner-Nix, J., Goldman, B., Hays, H., Lynch, M., & Moulin, D. (2003). Use of opioid analgesics for the treatment of chronic noncancer pain—a consensus statement and guidelines from the Canadian Pain Society, 2002. Pain Research and Management, 8(Suppl A), 3A-28A.
- Dhalla, I. A., Mamdani, M. M., Sivilotti, M. L., Kopp, A., Qureshi, O., & Juurlink, D. N. (2009). Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone. Canadian Medical Association Journal, 181(12), 891-896.