*This post was co-authored by David Juurlink
Monday's announcement by federal health minister Leona Aglukkaq that she will not interfere with the approval of generic OxyContin is just the latest development in what has become a major public health crisis.
In Canada, overdose deaths involving prescription medications now vastly outnumber deaths from HIV. By some estimates, prescription drug overdoses have killed 100,000 North Americans over the past 20 years. Astonishing though that may seem, these deaths are just the tip of the iceberg. For each one, there are hundreds of people whose lives have been ravaged by addiction to prescription drugs.
Much of this toll involves opioids -- painkillers including codeine, morphine and oxycodone, the active ingredient in OxyContin. Closely related to heroin, opioids produce euphoria, are highly addictive, and can be fatal at high doses or when combined with alcohol or other sedating drugs. Until the 1980s, physicians prescribed opioids primarily for acute pain (e.g., from a broken bone) and pain related to cancer. But today, opioids are more commonly prescribed to patients with chronic conditions like back pain and arthritis, often at doses that would have been viewed as unimaginably high just 25 years ago.
When someone has high blood pressure, there is good evidence that prescribing a drug for many years is beneficial. But with chronic pain, the prescribing of opioids for long periods of time (or at high doses) is not supported by good evidence. Comprehensive reviews of the scientific literature suggest that in many conditions -- arthritis, for example -- the dangers likely outweigh the benefits.
Nevertheless, aggressive marketing by pharmaceutical companies has convinced hundreds of thousands of physicians that long-term treatment with opioids is safe and effective, with little risk of addiction. Some aspects of this marketing campaign have been so misleading that in 2007 the manufacturer of OxyContin pleaded guilty in United States federal court to felony charges of "misbranding" and was fined $634 million.
OxyContin was designed so that the active ingredient would be released in stages over 12 hours, but the controlled-release mechanism was easy to defeat. People seeking a quick high could simply chew the tablets or crush them. For this reason, the manufacturer of OxyContin withdrew the drug from the Canadian market earlier this year and replaced it with OxyNEO. (It is worth noting that this move has also allowed the manufacturer to continue to sell its product at brandname prices for many more years.) OxyContin and OxyNEO have the same active ingredient, and when swallowed whole the two drugs are considered equivalent. OxyNEO, however, is more difficult to misuse because it is harder to crush or dissolve.
All opioids -- not just OxyContin -- can be misused, and the federal health minister is correct when she says that the law does not permit her to withhold approval of a generic formulation just because of the risk of misuse. But when the legal and regulatory framework results in a situation in which more than a dozen Canadians die each week because of an accidental prescription drug overdose, that framework needs to be changed.
How can we start to undo the damage? A critical first step is to acknowledge the extent of the problem, recognizing that for every celebrity death (Heath Ledger and Derek Boogaard, for example) there are thousands whose deaths do not make the front page. The misuse of prescription drugs and addiction remain taboo topics in our society. This must change. And while recognizing that untreated pain also remains a problem, it is time to stop heeding pleas for continued unfettered access to prescription opioids.
Physicians should re-evaluate how freely we prescribe these drugs for chronic pain, how readily we increase the dose, and we must abandon the widespread perception -- implanted in our psyche over many years by the pharmaceutical industry and its agents -- that opioids are safer and more effective than other pain relievers. We now know otherwise. Finally, we must become more comfortable treating patients who have become addicted to prescription drugs.
Governments at all levels also need to collaborate on a co-ordinated national approach. The federal government should pass a law requiring that all opioids be manufactured in a manner that makes them difficult to tamper with. It should also review whether opioids are being marketed for too broad a range of problems. Provincial governments should do their part, too. For example, they need to move far more quickly in developing online databases so that physicians and pharmacists can see whether their patients are trying to acquire opioids from multiple prescribers.
We don't need generic OxyContin in Canada. The federal government should still try to find a way to keep it off the market. But more importantly, governments at all levels need to work with doctors to do more to reduce the number of overdose deaths and the burden of addiction to prescription drugs.
Irfan Dhalla is an expert advisor with EvidenceNetwork.ca and both Dhalla and David Juurlink are physicians and researchers at St. Michael's Hospital and the Sunnybrook Health Sciences Centre respectively. Dhalla was until recently, and Juurlink continues to be, a member of the Committee to Evaluate Drugs, which provides advice to the Ontario Ministry of Health and Long-Term Care.
*This article first appeared in the Ottawa Citizen.
Brooklyn-born <a href="http://www.fbi.gov/about-us/history/famous-cases/al-capone">Al Capone</a> is one of the most notorious American gangsters of all time. During prohibition, Capone "controlled a vast criminal empire that smuggled drugs and ran prostitution and gambling outfits throughout the U.S.," <a href="http://www.celebritynetworth.com/articles/entertainment-articles/20-richest-drug-dealers-time/#!/10-al-capone-net-worth-1-3-billion_1074/">Celebrity Net Worth</a> writes. Capone, at one time an influential mob boss in Chicago, was <a href="http://www.fbi.gov/about-us/history/famous-cases/al-capone">sentenced to 11 years</a> in federal prison in 1931. At the time of his death in 1947, Capone was worth over a billion dollars.
The only woman to make it onto this list, Griselda Blanco -- known also as the "Godmother of Cocaine" -- was a ruthless drug lord for Colombia's <a href="http://en.wikipedia.org/wiki/Medell%C3%ADn_Cartel">Medellin cartel</a> during the 1970s and early 1980s. Blanco was assassinated in September by "<a href="http://www.huffingtonpost.com/2012/09/04/griselda-blanco-dead-cocaine-godmother_n_1853873.html">men on motorcycles in Colombia.</a>" Blanco had reportedly spent nearly 20 years in a U.S. prison before she was deported to her home country. At her height, Blanco is said to have been worth <a href="http://www.celebritynetworth.com/articles/entertainment-articles/20-richest-drug-dealers-time/#!/9-griselda-blanco-net-worth-2-billion_1075/">around $2 billion. </a>
<a href="http://www.pbs.org/wgbh/pages/frontline/shows/drugs/interviews/toro.html">Carlos Lehder</a>, co-founder of the Medellin Cartel, is a German-Colombian drug dealer who is currently serving a <a href="http://www.celebritynetworth.com/articles/entertainment-articles/20-richest-drug-dealers-time/#!/8-carlos-lehder-net-worth-2-7-billion_1076/">55 year sentence </a>in a federal prison in the U.S.
Brothers Gilberto (left) and Miguel Orejuela founded Colombia's notorious <a href="http://en.wikipedia.org/wiki/Cali_cartel">Cali Cartel</a>, which "at its peak supplied 70 percent of all the cocaine in the U.S. and 90 percent of the cocaine in Europe," according to <a href="http://www.celebritynetworth.com/articles/entertainment-articles/20-richest-drug-dealers-time/#!/7-the-orejuela-brothers-net-worth-3-billion_1077/">Celebrity Net Worth</a>. Both brothers are currently serving prison sentences in the U.S.
<a href="http://en.wikipedia.org/wiki/Jose_Gonzalo_Rodriguez_Gacha">Jose Gonzalo Rodriguez Gacha</a> was another co-founder of the Medellin Cartel (all six of them made the top 10). Gacha, acknowledged as one of the most successful drug dealers of all time, was <a href="http://www.pbs.org/wgbh/pages/frontline/shows/drugs/cron/">killed in a bloody shootout</a> by Colombian police in 1989, PBS writes. Thousands of mourners reportedly attended his funeral. In 1988, <a href="http://www.forbes.com/sites/erincarlyle/2012/03/13/billionaire-druglords-el-chapo-guzman-pablo-escobar-the-ochoa-brothers/">Forbes Magazine</a> included Gacha in their annual list of the world's billionaires.
<a href="http://www.economist.com/node/10097596?story_id=10097596&CFID=26317033&CFTOKEN=13306592.stm">Khun Sa</a>, known famously as the "Opium King," took an army of men into the jungles of Burma to cultivate opium in the 1960s. At the peak of his power, Sa had 20,000 men in his army and was trading some of the "<a href="http://www.businessinsider.com/pablo-escobar-named-richest-drug-dealer-of-all-time-2012-10">largest quantities of pure heroin ever</a>," Business Insider writes. <a href="http://www.economist.com/node/10097596?story_id=10097596&CFID=26317033&CFTOKEN=13306592.stm">Sa died in 2007</a> at the age of 73, reports the Economist.
The three Ochoa brothers -- <a href="http://www.pbs.org/wgbh/pages/frontline/shows/drugs/interviews/ochoajorge.html">Jorge</a> (left), Fabio (right) and Juan David (not pictured) -- founded the Medellin Cartel along with Carlos Lehder, Jose Gacha and Pablo Escobar, <a href="http://www.celebritynetworth.com/articles/entertainment-articles/20-richest-drug-dealers-time/#!/4-the-ochoa-brothers-net-worth-6-billion_1080/">Celebrity Net Worth writes.</a> All three made the <a href="http://www.forbes.com/sites/erincarlyle/2012/03/13/billionaire-druglords-el-chapo-guzman-pablo-escobar-the-ochoa-brothers/">Forbes' first World's Billionaires list</a> in 1997 and Jorge and Juan David are said to have been worth $6 billion each at the peak of their success (<a href="http://www.celebritynetworth.com/articles/entertainment-articles/20-richest-drug-dealers-time">Fabio's net worth is unknown</a>). The Ochoa brothers, all of whom have spent time behind bars, have since lost their fortunes. While his two brothers have since been released from prison, <a href="http://www.pbs.org/wgbh/pages/frontline/shows/drugs/cron/">Fabio Ochoa</a> is <a href="http://en.wikipedia.org/wiki/Fabio_Ochoa_V%C3%A1squez">serving a 30 year sentence</a> at a federal prison.
<a href="http://en.wikipedia.org/wiki/Dawood_Ibrahim#Recent_events">Dawood Ibrahim Kaskar</a> is "<a href="http://www.businessinsider.com/pablo-escobar-named-richest-drug-dealer-of-all-time-2012-10">India's most wanted criminal</a>," Business Insider writes. The head of the Indian organized crime syndicate D-Company in Mumbai, Kaskar is currently on Interpol's wanted list of organized crime and counterfeiting. Earlier this year, Kaskar's name was in the news again when a UK court <a href="http://www.hindustantimes.com/world-news/Europe/UK-court-orders-extradition-of-Dawood-s-aide/Article1-849884.aspx">ordered the extradition of his aide, Tiger Hanif</a> -- who is wanted in India for his alleged involvement in the planning of two bomb attacks in Gujarat in 1993, the Hindustan Times writes. For more, watch this video on <a href="http://www.youtube.com/watch?v=tXB1m2ZPuig">News X Live.</a>
Mexican drug kingpin <a href="http://en.wikipedia.org/wiki/Amado_Carrillo_Fuentes">Amado Carrillo Fuentes</a> became the head of the Juarez Cartel after assassinating his boss Rafael Guajardo. Fuentes, known as "Lord of the Skies" because of the large fleet of airplanes he used to transport drugs, was described as <a href="http://www.justice.gov/opa/pr/1999/September/432crm.htm">one of the most powerful drug traffickers in the world</a> by the U.S. Drug Enforcement Administration in 1999. Fuentes eventually died in a Mexican hospital in 1997 after <a href="http://www.businessinsider.com/pablo-escobar-named-richest-drug-dealer-of-all-time-2012-10">undergoing extensive plastic surgery</a> to change his appearance, Business Insider notes.
With his fellow Medellin Cartel co-founders all making the list, it seems appropriate that drug kingpin <a href="http://en.wikipedia.org/wiki/Pablo_Escobar">Pablo Escobar</a> -- the leader of the largest cocaine organization in history -- would top this list with a peak net worth of $30 billion. As Celebrity Net Worth notes, when Escobar "<a href="http://www.celebritynetworth.com/articles/entertainment-articles/20-richest-drug-dealers-time/#!/1-pablo-escobar-net-worth-30-billion_1083/">was eventually captured, the Colombian government built him a luxurious prison called La Catedral.</a> He eventually escaped and was gunned down in 1993 on the roof of a Medellin apartment." And if Escobar was included on the <a href="http://www.forbes.com/billionaires/list/">Forbes Billionaire rankings today</a>? <a href="http://www.businessinsider.com/pablo-escobar-named-richest-drug-dealer-of-all-time-2012-10">He'd be tied for seventh place</a>, notes Business Insider.
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