NOVEMBER 15-30, 2007


Sex & drugs case hurts pain care: MDs

NL's Dr Buckingham a "bad apple."
Docs fearful of opioid scripts

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.

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.

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.

"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."

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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