Whether St John's, NL, family physician
Dr Sean Buckingham gave drug addicts opioid prescriptions
in exchange for sex is for the jury in his ongoing trial
to decide. But pain care physicians from across Newfoundland
and Canada fear his alleged crimes have already done
their damage by making MDs too afraid to prescribe strong
pain meds.
Dr Buckingham was first arrested
in May 2005 after a long-running investigation by police
that involved wire-tapping, raids and 24-hour surveillance,
called Operation Remedy. He is currently facing 23 charges,
ranging from drug trafficking to sexual assault. During
the last week of October, the jury heard shocking testimony
from three women who allege they had sex with Dr Buckingham
in exchange for prescriptions for opioids painkillers.
TRICK
OR TREAT
The Buckingham case has become emblematic of what's
perceived by the Newfoundland public to be a physician-fuelled
addiction epidemic. Oxycodone prescriptions increased
a shocking 277% from 2001 to 2003, according to the
final report of the OxyContin Task Force the government
launched in 2003 to investigate the problem. Addiction
rates are uncertain, however; admission to the province's
scant addiction services for oxycodone abuse rose by
just 10% over the same period.
Numbers like these have contributed
to the widespread belief that doctors are handing opioids
out like candy. MDs say it's simply not the case. "One
or two doctors are prescribing inappropriately," says
Dr Lydia Hatcher, a St John's FP who specializes in
pain care. "One bad apple can become a huge thing."
The task force findings bear this out: just 1% of physicians
were writing the vast majority of opioid scripts. After
the task force report and Dr Buckingham's arrest, the
government demanded the College of Physicians and Surgeons
of Newfoundland conduct an audit of high prescribers.
Dr Hatcher is one of the physicians doing the reviews.
"I'm happy to say I haven't found any misprescribing
in the doctors I've reviewed," she says.
DRUGS
ON THE ROCK
So is Newfoundland awash in opioids? "I don't think
we have more or less," says Dr Hatcher. "In a small
province things tend to get magnified."
The problem, indeed, appears to
be present across the country. A groundbreaking study
published last November in the CMAJ revealed that prescription
opioids have usurped heroin as the illicit drug of choice
in all but Vancouver and Montreal. The trend was particularly
evident in the smaller centres studied, such as Saint
John, NB, a city with a very similar profile to St John's.
So why is this happening? There
are a lot of theories about why abuse of these drugs
is on the rise — from oil money to pharma marketing.
"Medical use and availability has doubled in the last
10 to 12 years," says study author Benedikt Fischer,
PhD, an addictions researcher at the University of Victoria.
"Canada prescribes 10 times more opioids than the UK."
In many smaller communities where
drug addiction has never been so visible, there's a
tendency to believe the addicts are just regular people
who got hooked on their pain meds. "This is a fallacy,"
fumes Dr Fischer. He says every addict starts off as
a seemingly regular person, but he strongly suspects
that all addicts — whether of prescription drugs
or street drugs — suffered from physical or mental
comorbidities and needs that weren't being met. "The
self-perceived identity may be different, but at the
end of the day both behaviours are illegal." He's says
he's sure that even if the prescription pain meds hadn't
been available, the people in his study would have been
on something illicit.
PHYSICIAN
BACKLASH
"I teach chronic pain all over the province and what
I hear over and over is 'I'm nervous prescribing these
drugs,'" says Dr Hatcher. She says her colleagues are
worried about three things: they don't want their patients
to get addicted; they don't want the College on their
backs; and they're worried they'll write a legitimate
prescription for a patient and it will end up on the
streets.
Dr Mark Ware, a pain specialist
at McGill, sees the same trend. "We have a hard time
finding physicians who will continue to prescribe opioids,"
he says.
Both docs agree the key is to better
educate MDs in how to manage pain patients. "There's
a lot of confusion about dependency and addiction,"
says Dr Ware. It's normal for patients to become dependent
upon opioids. What's not normal is when they crave them
and lose control. "In an ideal world, they wouldn't
get there," says Dr Hatcher. "The issue is documenting
and following up." She recommends you ask a lot of questions,
especially of new patients, and be hyperaware of patients
who come in early for refills. Dr Ware agrees. "If they're
properly prescribed and well-managed, addiction is very
unlikely."
As is so often the case, physician
resources appear to be at the heart of the problem.
"In Newfoundland, we don't have pain specialists, we
don't have pain clinics. There's no pay schedule for
pain care," says Dr Hatcher. "But one third of our patients
are in pain — we can't afford not to treat them."
HARM
REDUCTION
Things are looking up, however, on the Rock. "New cases
of OxyContin addiction are levelling off," says Tracy
Butler, program manager of Eastern Health's methadone
clinic, which was set up after the task force and is
already coping with long waiting lists.
One of the other chief recommendations
of the OxyContin Task Force was to establish an electronic
pharmacy network linked up with physician EMR systems.
Tamper-proof prescription pads have also been introduced
in the province. Margot Priddle, who's managing the
Pharmacy Network project, expects the pharmacy arm to
launch in early 2009, but admits the province has to
wait on EMR companies to make their sofware compliant
before the MD link-up can happen. "For now, it's business
as usual," she says.
Dr Fischer says we're very far
from an optimal approach to this issue, but he sees
a surprising (and controversial) public health silver
lining in prescription opioids overtaking illegals drugs
like heroin: "They're not injected, so there's less
risk for infectious disease, and they're controlled,
so there's less risk of overdose."
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