The first people I knew to be addicted to opiates were my friends George and Martha. That’s what I am going to call them, anyway: The subject is still sufficiently shameful to the world at large that I can’t use their real names. They were funny, warm, smart and Republican. George was tall and had a PhD and worked for the U.S. Navy. Martha was a tiny southern belle and entrepreneur until a car accident injured her back. She won US$200,000 in a lawsuit against the driver, but by then she was addicted to OxyContin, the original villain in the opiate overdose crisis that plagues North America to this day.
George managed to stay away from it until he cracked two vertebrae of his own after being struck by a car while commuting to work on his bike in Washington, D.C., several years later. “The whole philosophy of the 1990s was that the docs had this new miracle drug, and that you shouldn’t have to feel pain,” he remembered the other day. “But the problem is that it leaves you with a monkey on your back.” He could curb his craving if he could exercise, which on its own eased his pain, “but I had to be in pretty good shape to do that.” Going on the pills made him euphoric and manic. Going off them gave him intense cravings and blinding four-day headaches. “The drugs meant you could make it through anything, no matter what.”
I am very fond of George. He is a clever, well-read, subtle person. But it was as if a giant force field had somehow slipped over the pair of them during the decades of their addiction: They were there, but they often weren’t really there.
Fifteen years slid by that way. They abandoned their jobs, declared bankruptcy, stepped across the functional divide into full disability. George kept kicking opiates and then going back on them, but Martha “was an instant gratification type. So the pills worked a lot better than exercise.” Her weight tripled. She became less and less mobile. Shortly after Christmas two Januarys ago, she fell asleep on her sofa without the oxygen mask she had come to rely on, and suffocated. She was found by one of their two sons. She was 56.
That’s a common story. Since 1995, the year Purdue Pharma LC began its “muscular, misleading” marketing of OxyContin (to use the phrasing of recent court documents) as a non-addictive solution to chronic pain, more than 700,000 North Americans have died from drug overdoses – almost twice the number of deaths from COVID-19 so far.
Opioid deaths are the epidemic no one wants to think about within the epidemic no one can stop talking about. In the past 3½ years, more than 17,602 Canadians have died of opioid-related overdoses. And between April and June last year, as COVID-19 throttled the country for the first time, overdose deaths jumped a record 58 per cent over the previous quarter. Shutdowns and border closings restricted access to medicine and treatment programs and injection sites, thereby forcing users deeper into the ever more deadly illicit drug supply.
Successful attempts to curtail the prescribing of opioids have only made illicit use worse, while infuriating the one in four Canadians who suffer from chronic pain and actually need opiates. The opioid crisis has rattled the reputation of the medical profession, revealing just how little it knows about pain and how to treat it, at the same time producing a generation of young doctors now dangerously allergic to prescribing opioids of any kind.
Meanwhile, the hunt for a villain everyone can blame is in full bay: In November, Purdue, the inventor of OxyContin, pleaded guilty to criminal charges as part of a US$8.3-billion settlement with the U.S. Department of Justice. The company still faces another US$67-billion in claims by Canada’s provincial governments.
The opioid disaster will certainly outlast the COVID-19 version. There’s a vaccine against COVID. There is no vaccine yet against addiction (although researchers are hard at work on one), nor – more to the point – against the unavoidable human pain that lies at the root of addiction. But you’d never know that from the blasts of sanctimony issuing from every corner of the opioid debate – bereaved families, chastened doctors, blame-passing politicians, defensive pharma corporations, and the ever-shaming media. We still like to pretend we can control the pain of being alive.
The origin story of the opioid epidemic is a tale of a hundred thousand details, each more shocking than the next. Here are just a few of them.
For decades before Purdue began to sell OxyContin as a new “time-released” opioid for chronic pain in 1995 (and a year later in Canada), opioids (a class of synthetic opiates like morphine that bind to receptors in the central nervous system) were considered dangerously addictive. They were prescribed mostly to end-game cancer patients. But the Sackler brothers, the owners of Purdue, had virtually invented modern pharmaceutical marketing. Before they turned to OxyContin, they convinced the world that Librium and Valium were the universal cure to anxiety in all its forms, a trick they managed by targeting doctors, rather than patients, as their real customers.
Purdue pimped OxyContin as non-addictive and as a cure for pain (neither was true), paid record bonuses to salesmen and pharmacies, financed pro-opioid symposiums and speaking tours for supportive doctors, and in general spent 12 times its average drug marketing budget to overcome “opi-phobia.” They were aggressive tactics even for an industry where marketing campaigns routinely spend $20,000 per physician to persuade them to prescribe a new drug. The tactics worked. Over two decades Purdue sold US$35-billion worth of opiates in North America alone. That’s 10 times the current annual national budget of Rwanda.
But the company’s profits were just the tip of a new opioid-fuelled underground economy. OxyContin pills became currency, pharmacological bitcoin. The original 80-milligram OxyContin pill had the strength of 17 Percocets (a lesser opioid that contains acetaminophen), according to Jennifer Wyman, the associate head of addiction medicine at Women’s College Hospital in Toronto. “There was no need for them to make a pill so strong.” (The company also sold an even more potent 160 mg. version.) An “Oxy eighty,” crushed, was worth $1 a milligram on the street. OxyContin did for the underground drug economy what the invention of paper currency did for capitalism. For instance, in Williamson, W.Va., pop. 2,900, in the late 1990s and early 2000s, two pill-mill pharmacies four blocks apart reportedly sold enough OxyContin to supply 5,624 pills to every man, woman and child in town. “Diversion,” as the authorities called it, was rampant.
Still, there’s no market without a buyer. Doctors were keen to prescribe it, especially to long-time sufferers of chronic pain, who had few alternatives to quell their agony. According to Marni Jackson’s book Pain: The Fifth Vital Sign, published in 2002 just as OxyContin was sinking its teeth into North America, family doctors at that time received no more than two hours of instruction on the subject of pain – from doctors who themselves knew very little about pain – in the course of four years of medical school. (The number has since doubled to four hours for family docs. Veterinarians, by fascinating contrast, receive 75 hours of pain training. Everyone knows animals will sometimes be in pain, hence the intensive instruction. But why not humans?)
To most family doctors, chronic pain was a mysterious byproduct of disease (not an illness in its own right), notoriously hard to diagnose, difficult to cure and exceptionally common: Twenty-five per cent of Canadians suffer from chronic pain that lasts longer than three months. A pill that “fixed” that stubborn affliction, in a fee-for-service medical system? Yes, please. “Doctors want to help people,” David Juurlink told me recently. Dr. Juurlink is an internist and pharmacologist (and former pharmacist), and the head of clinical pharmacology and toxicology at the University of Toronto. He once eagerly recommended opioids, but later helped develop more restrictive national prescribing guidelines. “To suddenly be told that this ancient class of drugs, going back to the opium poppy, could now be used in a way we hadn’t previously, was a welcome message.”
By 2002 doctors were prescribing opiates 10 times as often as they had five years earlier. And by 2011, the number of people dying of opioid overdoses had quadrupled.
Purdue responded by reformulating OxyContin as uncrushable OxyNEO in 2010, just as Canadian doctors tightened opioid prescription guidelines for the first time. By then pain doctors were beginning to understand that there are different kinds of pain, and that they respond to opioids in very different ways. Dr. Andrea Furlan, a physiatrist at the Toronto Rehabilitation Institute, and one of the authors of the tightened 2010 rules, makes a distinction between “good” pain that has an obvious cause, and “bad” or chronic nociplastic pain, which she describes as a broken alarm system within the human body. “The alarm goes off even though there’s no fire. It keeps waking up the whole neighbourhood.”
Opioids are a godsend to someone with a broken femur, and – carefully managed – to someone overcoming chronic pain as well. But they can make nociplastic pain worse, which in turn makes the patient want more opioids. “Over the past 25 years,” Dr. Furlan told me recently, “physicians have prescribed opioids without knowing the difference. It’s almost like a positive feedback loop. Before you know it, the patient is on a massive dose of opioids, and is still in pain.” Even so, in 2015 – five years after the first tightening of prescribing guidelines – doctors still wrote 19.1 million opioid prescriptions, enough to treat one out of two Canadians.
Prescribing guidelines were revised and tightened again in 2017, but deadly overdoses continued to multiply. As doctors cut back on prescriptions, as health plans stopped paying for opiates, as the pills became harder to abuse, the exponentially larger number of people who now craved them turned to illegal sources – most tragically, to illicit and deadly fentanyl, a drug used in anesthesia and death-row executions alike, but now imported by Chinese and Mexican drug cartels. (It first showed up in Canada in 2013.) Fentanyl is 50 times stronger than heroin, and to illegal importers, 50 times more profitable: A kilogram of heroin yields 10,000 fixes, whereas a kilo of fentanyl gives you 500,000. Other narcotics even stronger than fentanyl (most recently xylazine, a livestock tranquilizer and cat emetic) have recently multiplied the profit margin all over again.
No wonder that by 2017, the number of opioid-related deaths in Canada was beginning to surpass the number of people who died in car accidents. Opioid death had become a feature of everyday life. And restrictions under COVID-19 have only made the drugs harder to get, the hunger worse, and using them more deadly.
The opioid overdose crisis seems to have no cure, partly because the medical community is (still) split on how to solve it.
At one end of the divide are (relatively few) anti-opioid fundamentalists who believe drugs such as hydromorphone and OxyNEO should be prescribed mostly for acute and temporary pain, and never under any but the most limited and controlled circumstances.
At the other treatment extreme are open-source advocates like Martin Schechter, an epidemiologist and addiction researcher at the University of British Columbia’s school of population and public health. Dr. Schechter believes addiction should be seen as a fact of life and an illness, rather than as a moral failing. He’s a principal in Fair Price Pharma, a new company that aims to provide unadulterated (therefore safe), domestically produced (therefore inspectable), injectable medical-grade heroin, i.e. diacetylmorphine, delivered in-syringe if required, to any patient with opioid dependence who has a prescription from their doctor. It’s a very hot idea: Dr. Schechter met last week with Toronto Public Health to discuss the possibility of setting up a clinic in that city.
“Every culture on Earth, as far as I know, has had some degree of drug use, since the beginning of time,” Dr. Schechter said in a recent conversation. “So some notion that you can eradicate drug use or incarcerate your way out of it is a fantasy. What we should do is recognize it occurs, and offer people prevention, but also treatment. And also, don’t let it kill people.” Similar programs have existed in less morally uptight countries, such as Switzerland and Britain, for 25 years. But so far even Vancouver, the eye of the overdose death storm, has only a handful of clinics where users can obtain prescription heroin. Their waiting lists are hundreds of names long.
In between these extremes are a wide and nuanced spectrum of alternatives. This is the territory of opiate agonist therapy – the use of milder, longer-acting opioid drugs such as methadone and buprenorphine to replace the shorter-acting opioids users are addicted to, again administered in safe, clean settings.
All these factions battle for acceptance and financial backing. The federal government has of late been spending money on safe supply and supervised injection sites, a high-visibility solution for a narrow (but arguably the most at risk) slice of potential overdosees. That’s okay with open-supply fans, but troubles doctors like Vincent Lam, the Giller Prize-winning writer who also directs Toronto’s Coderix Medical Clinic, which specializes in opioid agonist and other behavioural therapies for substance abuse. Providing safe supply may be a shame-free way to get safe drugs to long-term opioid abusers, Dr. Lam concedes. But it opens darker possibilities, such as tempting the unaddicted and undermining patients who had overcome their dependence.
“I do not feel that is a wise or considered approach,” Dr. Lam says, and he’s happy to supply examples. The federal government’s recent embrace of so-called “safe supply” hydromorphone (another opioid) has increased quantities and lowered its street price to a tenth of what it was. “Effectively what we are doing is subsidizing the trade in prescribed hydromorphone, and its use in the illicit markets,” Dr. Lam says. He has heard recent reports of users selling their hydromorphone to buy fentanyl – all as a result of a government program intended to create an alternative to dying from fentanyl.
That’s another challenge to eliminating opioid abuse, and the deaths that come of it. The opioid world is the kingdom of unintended consequences.
Here’s a thought. What if, instead of talking about the overdose crisis in terms of drugs and opioid use disorder (the current euphemism for addiction), we talked about the pain users are trying to mask? The entire crisis has its roots in pain, and our unsteady relationship to it – both the emotional and psychological pain that drives people to become addicted, and the chronic medical pain that seems impossible to cure. It is the long-term abusers who get the most persistent publicity – often the underclass, the poor, the precarious and the structurally dispossessed, Indigenous people prominent among them. But “the highest-risk Canadian for overdose death today,” according to Hance Clarke, director of pain services at Toronto General Hospital, “is one of the millions of Canadians with chronic pain that are on more than 300 milligrams, and their doctor retires.” The new generation of doctors is unlikely to renew that prescription.
The opioid crisis has made it clear to researchers, however, that those with long-term addictions and chronic pain sufferers – the two main drivers of opioid overdose deaths – have a great deal in common.
In a well-known 2004 study of more than 17,000 middle-class Americans, a San Diego researcher established that the compulsive use of nicotine, alcohol and injected street drugs increased almost in lockstep with the intensity of “adverse life experiences” during childhood. The researcher, Dr. Vincent Felitti, even quoted T.S. Eliot’s Four Quartets: “In my beginning is my end.” This understanding of addiction is unpopular with some neurobiologists and even some drug-treatment programs that use drugs to fight drug use. “Our findings are disturbing to some,” Dr. Felitti wrote at the time, “because they imply that the basic causes of addiction lie within us and the way we treat each other, not in drug dealers or dangerous chemicals.”
Most addiction specialists now acknowledge this. Dr. Schechter, the would-be supplier of prescription heroin, readily concedes, “a lot of people end up using heroin as a way of dealing with trauma of some kind, whether it’s anxiety, pain from bad childhood memories or horrible experiences. There’s a common theme of numbing psychic psychological pain as well as physical pain.”
The trauma theory doesn’t explain all addiction. Genetics affect an individual’s propensity to abuse drugs or drink or tobacco, as do individual traits. Redheads seem to experience more pain than others. People who inherit a “fast” metabolizing gene from both parents not only process caffeine faster, they may have a greater tendency to addictive behaviour. Dr. Clarke points out that at least 5 to 7 per cent of the world’s 200 million annual operations leave their subjects with pain disability problems a year later.
One in four teenagers suffer from chronic pain for largely unknown reasons, according to Melanie Noel, a pain psychologist at the University of Calgary. Other kids wake up after puberty with crashing headaches. “And what is the cause of it?” Dr. Noel asks. “That’s the million-dollar question. And everyone is trying to figure it out. And I doubt we’ll ever find a clear, simple answer.” What she does know is that we keep looking in the wrong places for the answer. “Many of the people addressing pain are not addressing the trauma. And a lot of people treating trauma are not looking at chronic pain. A lot of this stuff has its roots in childhood.”
Concentrating on pain and its causes, rather than on the drugs that merely mask it, has opened new routes to treatment. At the Toronto Rehabilitation Institute where Dr. Furlan runs her clinics, pain is now a multidisciplinary program that involves multiple specialties: mindfulness and physiotherapy share the stage with cognitive behaviour therapy, acceptance and commitment therapies, lidocaine injections, massage, exercise, yoga, meditation, nerve blockers and – when appropriate – tapered doses of opioids. (The clinic has a four-month waiting list.) “People with a disposition to addiction have pain,” Furlan says. “And trauma predisposes people both to chronic pain and to opioid use disorder.”
I recently met one of her patients, a man named Dan Jakobi. In 1996, at the age of 11, he was in a car accident that left him with an open head brain injury, a tracheotomy, spinal and leg wounds, missing cartilage, degenerative bone damage and (literally) shattered nerves. Dr. Furlan – who has legendary status among her peers in this regard – set about reorganizing his pain systems. He was in the hospital for six months, in a wheelchair for another six. He had to relearn how to walk and talk. He has been in steady pain ever since, despite there being no known physiological cause for some of it.
Mr. Jakobi’s pain is the pervasive and traumatic kind that goes beyond a physical cause and is rooted instead in what Dr. Rob Bonin, a researcher at the University of Toronto’s Leslie Dann faculty of pharmacy, refers to as “maladaptive memories” that “somehow have to be removed, rather than suppressed.” If pathological pain is a misfiring memory, the theory goes, maybe it can be modified. That’s the cutting edge of pain research these days: the possibility that one day a patient’s faulty, phantom recollection of chronic pain will be excisable, sort of the way Will Smith and Tommy Lee Jones wielded their memory-wiping stick in Men in Black.
Mr. Jakobi is now 36. He takes up to eight Extra Strength Tylenol a day when he needs to, but never opioids. He is fully engaged in Dr. Furlan’s program: uses muscle relaxants when required, gets lidocaine injections, and is on a small dose of anti-depressants, to help him deal with his “anguish” – his awareness that he is “not able to do what other people my age do.” He bikes (he just bought a Peloton) and goes to the gym religiously and consults a physiotherapist fortnightly. He does half an hour of aerobics or yoga every day without fail, plus 15 minutes of guided meditation, during which he contemplates all the things he loves most. “We have to live with pain,” he has concluded, from the dark pit of his experience. “I think pain will always be in our lives, no matter what. Pain is everywhere around us. But I strongly believe we can learn not to let that disturb our lifestyles.”
Or, as Dr. Furlan puts it: “We have to replace the alarm system in the home. We have to taper them off opioids. The brain has to learn to produce endogenous opioids to replace the synthetic ones. Then we have to retrain the system to feel normal pain again.” Most of all, she says, “They have to accept that they will have it for the rest of their lives. But by then they have relearned their approach to pain.” This is learned resilience. “When people are achieving their goals,” says Dr. John Flannery, one of Dr. Furlan’s colleagues at the University of Toronto’s Centre for the Study of Pain, “it’s very, very easy to get rid of the opioids. Because now the satisfaction is sustained.”
Pain, in other words, can be useful if you don’t simply mute it with opioids. “My pain is a friendly reminder,” Mr. Jakobi told me, “that we need to look in on each other, that we need to keep on working on ourselves the best we can.”
Many of the injuries that cause chronic pain and opioid addiction, of course, are less visible than Mr. Jakobi’s. They’re the psychological wounds that stem from serious emotional and physical abuse, but also, evidence shows, from nothing worse than neglectful workaholic parents, or stretches of alcoholism, or persistent fractious arguing, or the turmoil of disability, or online shaming, or sleep problems, or even the day-to-day mini-traumas of divorce and lost jobs. In some cases, all it takes to produce a person with recurring physical or emotional pain and a predilection to substance abuse (be it beer or buprenorphine) is the rumbling low-grade anxiety spiked with occasional outright panic that comprises being a parent. Hundreds of thousands of people have died from the misprescribing and misuse of opioids, and then from our misguided attempts to control that abuse. What’s just as astonishing is that more of us weren’t snared along the way. Trauma and addiction live closer than most of us think.
To some physicians, that suggests a deeper solution to the spectre of overdose deaths. “We need to think really, really carefully about the way our society and our economy functions in early childhood development,” Dr. Lam says. “We really have to be thinking about parental-leave policies, about high-quality early childhood education, about how to support parents who might be having a tough time adapting to life as parents. And that’s probably every parent in Canada.”
To address the opioid crisis at its root, we need to give people alternatives to opioids to deal with the pain of life. “Do we need to publicly fund physiotherapy?” asks Nav Persaud, a physician and professor of medicine at the University of Toronto who has loudly and publicly criticized opioid prescribing and marketing. How about including long-term talk therapy in provincial health plans, from an early age? “Do we need to make sure people are triaged properly so they’re not on long waiting lists for surgery? I think everyone would agree it’s much better to prevent addiction than to treat addictions.”
Such services, to say nothing of multidisciplinary pain clinics and enlightened pain doctors, are hard to come by. They cost money politicians are loath to spend on controversial causes – though nowhere near the $40-billion the opioid crisis cost Canada in 2019 alone, according to the most recent Canadian Pain Report. It’s easier to treat the symptom, rather than the cause.
But maybe the COVID-19 pandemic has something to teach its cousin, the epidemic of opioid overdoses. The likelihood of dying from COVID-19 is slim, overall, but it’s universal: Ten days from now, any one of us could be gasping for life in a crowded hospital. The purpose of the lockdown was to minimize that possibility – for most of us to take a hit, freedom-wise, to limit the danger to the statistically unlucky few.
Pain, too, is universal. Pain, in fact, is the lingua franca of human existence: It isn’t for nothing that a man in agony nailed alive to a wooden cross is the symbol of the world’s most widely practised faith. No one escapes pain, of any variety, in the course of their life. If COVID and its lockdowns have offered up any lesson at all, it is this: that what we miss most is each other, or at least the possibility of each other. We are each of us the antibody to the virus of indifference that also lurks in everyone.
“If we are to come out of this crisis less selfish than when we went in,” Pope Francis writes in his new book, Let Us Dream: The Path to a Better Future, “we have to let ourselves be touched by others’ pain.” You don’t have to be Catholic or any other kind of believer to grasp his point. Instead of shying away from pain and addiction and opioid abusers and their bottomless craving, of which we are compulsively afraid, instead of trying to drug them into invisibility, what would happen if we tried to make childhood less terrifying, and trauma less secretive, and the lives of the damaged less shameful?
From which of our own deadly addictions – to the illusion of self-sufficiency and merit and perfection, to the smug belief that we can control our lives, to our unquestioning faith in success and doing better than others – would that gesture finally free us?
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