From emergency to catastrophe. Lack of addictions programming a national shame.

I don’t usually do ‘breaking news’ stories…and well I guess I’m not doing it now either.  This news isn’t new at all, it’s just finally getting some mainstream attention as the situation is set to get exponentially worse.

The problem with OxyContin

OxyContin, also known colloquially as hillbilly heroin, is a powerful and potentially addictive painkiller.  As has been noted in a number of other news reports, abuse of this drug is a Canada-wide problem.

A study on the use of opioids (including OxyContin) among beneficiaries of Ontario’s public drug plan highlights a number of concerns.  More and more prescriptions are being written, and the doses are getting higher, leading to an increase in opioid-related deaths.  And this is what we know about legal sales.

Recently Purdue Pharma Canada has announced it is releasing OxyNEO, a supposedly harder to tamper with version of OxyContin that has been available in the US since April of 2010.  ‘Regular’ OxyContin will no longer be available in Canada as of March 1st when stocks are expected to run out.

A crisis is declared

In November of 2009, the Nishnawbe Aski Nation (NAN), which represents 49 First Nations in northern Ontario (a population of about 45,000 people) declared a “Prescription Drug Abuse State of Emergency“.

This resolution notes that prescription drug abuse, particularly of opioids like OxyContin, is an escalating crisis and calls upon both levels of government to immediately enhance community-based programming to deal with it.

By September of 2011, policing and addictions were stretched to the breaking point in many NAN communities and the response from provincial and federal governments is described by NAN as ‘minimal‘.

Another First Nations crisis ignored.

Responsibility for health care services

In Canada, most people access health care services through provincial programs and infrastructure. Status Indians and ‘recognised’ Inuit are a federal responsibility when it comes to health care.

Health Canada provides First Nations and Inuit with “a limited range of medically necessary health-related goods and services to which these individuals are not entitled through other plans and programs”.

Under this Non-Insured Health Benefits (NIHB) program, certain prescription and over the counter drugs are covered (paid for) if the patient does not have private insurance.  Only drugs on the NIHB Drug Benefits List are eligible for this coverage.

No OxyContin for First Nations/Inuit

On February 15 of this year, Health Canada announced that all “long-acting oxycodones” such as OxyContin have been removed from the NIHB Drug Benefit List stating*:

NIHB will consider requests for long-acting oxycodone on a case-by-case basis and coverage may be granted in exceptional circumstances (e.g. cancer or palliative pain) when alternatives on the NIHB DBL have failed or are not appropriate.  Continued coverage of long-acting oxycodone will be permitted for clients who have received coverage of long-acting oxycodone through NIHB in the three months prior to February 15, 2012 (i.e. these clients will be grandfathered).

Thus legal sources of OxyContin will become unavailable to all Status Indians and recognised Inuit across Canada through the NIHB.  Those who legitimately need this medication will not be able to receive it in the future.

Still available to non-natives

In most of the rest of the country, OxyContin or its replacement OxyNEO will continue to be available to those who need it.  There are some provincial exceptions.

PEI has recently instituted similar measures as those taken by the NIHB, pending a review of treatment with oxycodones compared to other drugs.  Newfoundland heavily restricts access to OxyContin, but allows at least 15 other oxycodone drugs under its public drug plan.

More worrisome is the example of Manitoba, where access to OxyContin was restricted last year, reserved for patients with specific ailments only.  Fears of this leading to a surge in crime was quickly confirmed as desperate people with OxyContin addictions  unable to get into treatment programs turned to armed robbery.  This in a urban centre with considerably more addictions resources than isolated First Nations or Inuit communities.

UPDATE: Ontario and Saskatchewan are both taking a similar approach to PEI and Health Canada, and severely restricting OxyContin/OxyNEO from now on.  However, similar concerns about lack of addictions programming for populations in these areas are being raised.

A dam about to burst

The situation in many Nishnawbe Aski Nation communities has been already bad enough to warrant the declaration of a State of Emergency.  Now the NAN is warning of even worse.

Without OxyContin available, individuals will experience withdrawal.  Symptoms may range in severity from stomach upset, muscle and bone pain, anxiety, restlessness, increased heart rate and blood pressure to depression and suicidal ideation.

“In the absence of any regular treatment, a public health catastrophe is imminent, as there are thousands of addicted individuals with rapidly shrinking supplies – likely leading to massive increases in black market prices, use of other drugs, needle use/sharing, and crime,” said Dr. Benedikt Fischer, a senior scientist at the Centre for Addictions and Mental Health.

Health Canada acknowledges that most people in NAN communities are not getting the drug through legal prescriptions funded by the government.  How withdrawing OxyContin from the Drug Benefit List will in any way address abuse is unclear.

Despite a stated willingness by Health Canada to fund drugs used to treat opioid dependence such as methadone (which is not available in most remote communities) and suboxone (but only on a case-by-case basis), no mention is made of what addictions programming will be put into place to deal with the worsening situation.

In short, the resources are not there to help deal with what is about to be a flood of people with addictions going through serious withdrawal in these communities.

From emergency to catastrophe

Action needs to be taken now to ensure that adequate resources are provided to communities struggling with such severe addictions problems and lack of treatment programs. It is unacceptable that an emergency gone unheeded should be allowed to turn into a catastrophe, yet again.

The Nishnawbe Aski Nation has developed a Prescription and Drug Abuse framework focused on four areas:

  1. Treatment
  2. Security
  3. Prevention
  4. Addressing root causes

However, with the exception of $100,000 from Health Canada and INAC for Prescription Drug Abuse Coordinator for the 2010-2011 fiscal year, no support has been given by provincial or federal governments to support this framework.

Learn more

A online documentary titled The Life You Want provides a stark view of how lack of access to addictions treatment is already affecting many First Nations and Inuit people in remote communities.

Also available for download attached is a copy of a Marten Falls Ogoki Report to Community (Word document). Chief Eli Moonias, NAN Prescription Drug Abuse Task Force representative has given permission for this report to be shared with others to create awareness about the impacts of PDA in a remote First Nation.  I warn you, this is not light reading.

NAN has also released a briefing note on the widespread nature of OxyContin addictions in many of its communities, outlining as well the obstacles to accessing adequate treatment.

My thanks to the Health Policy & Planning Department of the Nishnawbe Aski Nation for sharing this information.

 

 

*Health Canada press release provided by Stéphane Shank, Media Relations, Consultation and Communications Branch, Health Canada

A shorter version of this article was published on rabble.ca on February 19th, 2012 and on Indian Country Today on March 5, 2012.

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17 Responses to From emergency to catastrophe. Lack of addictions programming a national shame.


  1. Dave MacKay says:

    Hopefully there will appear some solutions for this problem which is affecting all of our society.

    Thank you for your article.

  2. Sharon Jackson says:

    Ask your webmaster to make your h1 font smaller. I always think you are yelling at me. The font is larger than your heading font, which should not be. I usually make my h1 size 22px, h2= 18 and h3=16 and it works out nicely. Glad to see your new site up and running!

  3. Becs says:

    There are some inaccuracies with your post.

    “No OxyContin for First Nations/Inuit…Thus legal sources of OxyContin will become unavailable to all Status Indians and recognised Inuit across Canada through the NIHB. Those who legitimately need this medication will not be able to receive it in the future.”

    First of all, OxyContin will be unavailable for everyone in Canada. OxyNEO will become the replacement. I am unfamiliar with this drug, however I have been told it is harder to abuse this new version (harder to snort/inject, etc.).

    Secondly, everyone currently prescribed OxyContin will be switched to OxyNEO. This should not be a problem for anyone who has a legitimate pain issue requiring the use of this narcotic. It will be an issue for those who currently abuse OxyContin.

    NIHB pays for medications. That is it. NIHB cannot decline a prescription – they can just refuse to pay for it. So if a MD writes a prescription for OxyNEO and it is declined by NIHB the patient still has the option to pay for the medication themselves.

    Finally, NIHB does not just say “no”. They give the MD the option of filling out a special request form for the medication – and typically they are pretty reasonable. OxyNEO should be reserved for certain circumstances, and therefore I am all for NIHB reserving the right to consider requests on a case-by-case basis. It is a drug that absolutely should not be used as a first-line narcotic. If other narcotics are not working to manage the pain, OR in certain circumstances where pain is known to be resistant to the usual narcotics (i.e. cancer), NIHB will pay for the prescription.

    I agree that there will be a problem for peoples currently addicted and misusing OxyContin. OxyNEO will be harder to misuse and get high off of. Unfortunately addiction is a tough science and there are no real easy solutions. People get addicted to Methadone and never stop using it. Treatment centers outside of communities are not the best solution either – remove people from their surroundings makes it easier for them to stop, but then once the treatment program is finished they go home to the stress/environment that they used in.

    • 1. I pointed out at the beginning of the article that all OxyContin will become unavailable in Canada and supplies are expected to dry up by March 1st.

      2. OxyNEO will not be funded for First Nations and Inuit via Health Canada, while aside from PEI, no other such blanket bans under public drug plans are being put into place.

      3. OxyNEO has been available in the US since 2010 and a quick google search will provide you with more information that you ever wanted on how to ‘get around’ the ‘tamper-proofing’. I deliberately did not include that information in the article, but it is certainly something I looked into.

      4. First Nations and Inuit currently being prescribed OxyContin will be switched to OxyNEO but you are incorrect when you state that this will only impact those who are abusing the drug illegally. What your claim ignores is why OxyContin is prescribed in the first place. Those conditions requiring treatment with oxycodones like OxyContin and OxyNEO are not going to magically go away. New need for legitimate prescriptions will continue, but will no longer be met.

      5. I very specifically explained the contest of the NIHB, which like other public drug plans covers the cost of prescription drugs when there are no private plans in place. And like all other public drug plans, the patient does indeed have the choice to purchase the prescription out of pocket. That is not at all the point.

      If the NIHB only covered three prescription drugs and all others had to be paid out of pocket by First Nations and Inuit, one could attempt to, as you have here, claim that this is not a ‘denial of access’ but merely a refusal to fund any other drugs. What your argument ignores is that decisions like these do in fact deny people access to certain drugs because of the high cost involved. OxyContin is not cheap, nor will OxyNEO be. Delisting this drug will have the effect of making it unavailable to many First Nations and Inuit people.

      6. The issue here is abuse. Communities have been literally begging the government to address this epidemic and institute funding and infrastructure to address the problem. Instead, the response is to restrict a drug through legal means, when the bulk of the abuse taking place is not through legal supplies anyway. This response by Health Canada ignores the serious needs of the communities, impacts the people who legitimately need pain management via OxyContin or OxyNEO now and into the future, and in no way considers the on the ground affect that these communities are going to experience as addicts switch from OxyContin to other drugs…while going through serious withdrawal.

      So I contest your claim that there are inaccuracies in my post.

  4. nokamis says:

    I absolutely agree. Restricting the drug is nonsensical and bears a signature of ignorance at best and abuse at worst. The infrastructure needed to address this issue and the problems largely fueling this epidemic require committed resources by the powers that be for First Nations to develop a framework and a strategy (unlike the existing piecemeal approach). The people have a whole lot of work ahead beginning with collective voices highlighting the issue…just as you are doing here. Miigwech.

  5. Becs says:

    This is what is inaccurate:

    “2. OxyNEO will not be funded for First Nations and Inuit via Health Canada, while aside from PEI, no other such blanket bans under public drug plans are being put into place. ”

    The following paragraph appeared in your original article:

    “NIHB will consider requests for long-acting oxycodone on a case-by-case basis and coverage may be granted in exceptional circumstances (e.g. cancer or palliative pain) when alternatives on the NIHB DBL have failed or are not appropriate”

    Therefore, OxyNEO will be available through NIHB providing the MD has tried other, first-line medications first, and in certain circumstances (i.e. cancer).

    There are many medications on the NIHB limited access list. Morphine is one of them. It is not hard to get NIHB to pay for these medications, you just need adequate documentation (which as a health care provider, I feel is quite reasonable).

    • Let’s please not minimise the changes being imposed.

      Oxycodones are being delisted entirely. From now on only grandfathered prescriptions and exceptional cases will be examined, and all on a case-by-case basis. As anyone who has had to go through the NIHB knows, asking for exemptions can be a very time-consuming and frustrating process, even going through the ‘prior approval’ process. If you have to go back to your doctor for paperwork to support your application and you live in a community with spotty staffing (ie, nursing staff but doctors only on rotation) then you are literally waiting, in pain, until you can see the doctor again. And you may end up denied anyway.

      Abuse is a huge issue, and as pointed out in the article, the problem also involves the medical system as health care professionals oversubscribe (amounts of prescriptions and dosages both). One would assume this problem would be particularly severe where limited medical staff are available and drug-seeking behaviour cannot be as easily assessed/monitored. So the restriction of this drug is not in itself a bad thing. It does little to address the illegal sources of this drug, however.

      Many First Nations and Inuit communities are struggling with addictions to oxycodones and are not receiving adequate addictions treatment support. The decision to delist these drugs and to provide no further addictions services, is setting these communities up for a rash of suicides and criminal acts as severely addicted people go through what is apparently a quite horrible withdrawal. The switch from OxyContin to OxyNEO is also a big part of this…until addicts figure out how to abuse OxyNEO that is.

      It is utterly unconscionable to approach this situation in such a short-sighted and paternalistic manner. No support for communities dealing with addictions, and apparently a belief that First Nations and Inuit people are incapable of legally taking a prescription medication that most non-natives continue to have access to.

      If these drugs need to be restricted across the board, let it be done. But let it be done in a way that ensures adequate services are put in place first to deal with those who are addicted.

  6. Becs says:

    Quite frankly I am not sure why I keep reading this blog .

    I live on a reserve with “spotty staffing”. No problem whatsoever getting that paperwork signed – if there is no physician on site the nurses can fax the required paperwork to the closest hospital and have a physician sign it there. I deal with this extra paperwork continuously and I now know most of the medications that require this extra paperwork. Therefore this extra stuff can be done at the same time as the prescription. If it is forgotten, within hours of faxing the prescription the pharmacy will send back the required paperwork.

    Keep in mind NIHB is a drug benefit program. Just like any other drug benefit program there are limitations. Many Canadians have absolutely no drug benefit coverage and are on their own for the entire costs of medications. Even with good drug plans there are still things that are not covered or are only partially covered.

    There are so many addiction issues on reserves. And unfortunately many addictions are not just because someone had a past physical injury and then became reliant on their painkillers – it develops because of long histories of abuse, hopelessness, poor role models, boredom, poverty, learned helplessness, loss of culture/self, etc. Providing more addiction services would help – but it would not fix the problem. Addiction has developed because of other, more insidious issues. We need to figure out how to fix those things too! Outside resources can assist, but the real problem solving needs to happen from the inside.

    “…a belief that First Nations and Inuit people are incapable of legally taking a prescription medication that most non-natives continue to have access to.”

    I am not sure how you came to this conclusion. How does this mean they are incapable? Drug benefits change all the time! And what about a non-native who works a minimum wage job with no drug benefits? This person often has difficulty affording basic prescriptions, let alone expensive narcotics. As mentioned previously, Oxycontin will continue to be available through NIHB however there will be more proverbial hoops to jump through (and really, it is an extra piece of paper that requires maybe 5 minutes to fill out). Furthermore, a native person still has the option of paying for it themselves if their request is denied through NIHB (similar to that non-native without drug coverage – a category that a number of Canadians fit into).

    I feel that this is a good step. Sure, more addiction services could be used – however I do not think that alone will solve the multifaceted problems many First Nations face.
    Many health care providers are too liberal with their narcotic prescriptions. This has resulted in many people being treated with narcotics that were too aggressive for their pain (especially in people who have a higher likelihood for addiction). Physicians working on reserves figured this out a little before everyone else and had started cutting back on the liberal narcotic use (using evidence-based literature). Unfortunately a number of patients leave the reserve to get healthcare. The physicians from these other cities often do not perform risk assessments (re: addiction) prior to prescribing narcotics. Once patients return home the reserve docs were left with the mess to figure out. Having Oxycontin as a limited use NIHB drug will prevent outside physicians from being too liberal with their prescriptions.

    • Quite frankly I am not sure why I keep reading this blog .

      I can’t fathom the answer to this either, when you seem to be convinced that we are at complete odds on this. And unless you believe that the current state of addictions programming in First Nations an Inuit communities is sufficient…then we aren’t disagreeing on anything particularly fundamental.

  7. Debra Dublin says:

    I want to agree with the writer of the blog on the difficulty of getting NIHB to cover a medication when there is no coverage. I am a Status Indian from Manitoba. After exhausting all other prescription avenues, it became necessary for my doctor to prescribe a medication for me that was not covered under NIHB. My doctor had to fill out a form describing my specific need,and why no other drugs which had coverage did not work or had failed to work. It was time consuming for him and his support staff, and I had to wait until coverage was granted. If my doctor had not been willing to go to such lengths, I could not afford to pay for the drug myself, and I would have gone without it. This happens often to First Nations people who simply give up and go away without proper drug coverage. If ‘Becs’ says it is a simple process, perhaps they should try it from our perspective. It is not so easy–unless you have a cooperative doctor, which I, fortunately, have.

  8. Chelsea, I found your article in Indian Country Today, because they also had an article on my book about addiction; The Thirteenth Step. I found it to be more than coincidence(because I dont believe in coincidence) that there were 2 articles on Oxycontin in the same issue, because I am working on a book now all about the pandemic that is oxycontin, and the fact that this is only the beginning of a nationwide disaster because of this drug. While Purdue might be pretending to come up with ‘tamper proof’ oxycodone, it is all a lie, they are in the business of getting people addicted, and are committed to it. Recently they have also been linked to the Heroin trade, so they can cover every aspect of this evil drug. While their is legitimate uses for opioids at these strength levels, it is limited to terminal patients, never meant to be used on average pain situations. The whole story about how it came to be, and where it is going, will stun even those who think they have heard it all. I know first hand about the power of this drug, and was nearly killed by it. Because of that, and because I am committed to putting a stop to all addictions, this is my passion. I would like to correspond more with you, but for now, I want to alert you to a red flag I saw in your article. Under no circumstances should you advocate for or try to get a methadone program going to help ease the withdrawals coming from this drug. What you are going to see is an incredible influx of cheap heroin coming into all of the communities, it is the way they work it. Methadone addiction is actually worse than heroin, and is next to impossible to get off of it. You must demand a Suboxone program of weaning the patients down to nothing over a period of time, but do NOT get them on methadone, or you will never see an end to the problem. All methadone does is help addicts hold off until they can get their next oxy or heroin fix, they never get off of any of it, and the withdrawals from methadone are worse than all of them. If anything is to be done, it must be through a suboxone detox program, and Purdue is obligated to supply the system, it is part of the many, many penalties and fines they gladly pay to keep illegally in business getting all of the world addicted to their drugs. Along with the suboxone treatment, you must have the patients in a very structured counseling program, or they WILL relapse, the very day they take their last crumb of suboxone. This addiction is stronger than any that ever existed, we are just now discovering how it completely re-wires the brain functions, and disables the addict from any rational thoughts of survival for over 6 months after their last use of oxycontin. I offer my services to you, but I know first you must demand this entire treatment program to be funded and put into place, it is the only chance you have. I am happy to speak to anyone, or talk anywhere about what you are up against. If nothing else, at the very least, do not allow the methadone program any where near you, or you will regret it forever. Very sincerely, Robert Hayward, AODS_RRW, CA. goodmedcn@gmail.com

  9. Linda Barkhouse says:

    I agree completely. Excellent strategy!
    Our company Encompass Health Systems Inc. which implements the ‘Concepts in Pain Management’ program in Essex County has been saying the same warning for years. We are implementing a comprehensive pain management and concurrent substance abuse/depression continuing education program for professionals. We need to intervene early and stick to the fundamentals of pain management and reduce the suffering associated with addiction.
    The response from the federal and provincial governments has been appalling as the daily death toll has now reached a level to become the first non-infectious pandemic in history.
    Stay hopeful. There is a solution – thank you for this article!

  10. Mike says:

    You said it right there: oxycodones are so powerful no reasonable or ethically conscientious doctor would prescribe it to someone that isn’t terminally ill. Why isn’t the community going after the doctors prescribing these drugs to communities without the resources or infrastructure to deal with such rampant addiction ills? Why is leadership and those administering public services in these communities held accountable for their inability to do so effectively? Why must it be the federal governments failing? I’ve worked at clinics that operate and meet our mandate with extremely scarce resources. The right people can make magic with very little and acheive their goals, the world is full of examples. People need to want to help just as much as people that require that help need to want it. And for the record, the other posters were correct about your disengenous writing. Right under a direct quote explaining the NIHB will consider case by case needs for long-term oxycodones, you said: “Those who legitimately need this medication will not be able to receive it in the future.” Judging by your vehement responses to others critiques, I’d guess this isn’t the first/last time you’ve been accused of being contradictory.

    • Since this article was first written, there has been a complete ban under the NIHB for the prescription of oxycodones to Status Indians (who access healthcare through the NIHB). This is not a ban that exists for anyone else.

      The contradiction lies in the claim that this is not a completely racist ban, impacting only one group: First Nations.

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