The Pain with Painkillers.

In Editorial, Opinion by Edmund Kwok5 Comments

There is a medical horror story told to all medical students since 2004. It is a story of thousands and thousands of deaths related to a prescription painkiller: Rofecoxib, or better know by its trade name Vioxx.

In a nutshell, Vioxx was marketed as an important pain management option for patients suffering from chronic painful conditions like arthritis. It didn’t save any lives, but promised to relief some of the morbidity associated with painful conditions. The problem was, it carried a nasty side effect of increasing risk of cardiovascular death. In fact, over the course of 5 years before it was withdrawn from market, an estimated 60,000 deaths have been attributed to Vioxx use. This horrific tale has been highlighted since then in the hopes that we’ll learn something about the dangers of prescription medications, their potential ill effects, and the need for regulating the balance of risk/benefit on a population level.

Well it seems we’ve learnt nothing.

Canada’s Health Minister Leona Aqlukkaq just recently gave the green light for a cheaper generic version of OxyContin, a long-acting opioid painkiller that’s responsible for over 1000 deaths a year. Sure, the direct mechanism of how OxyContin kills is different than that of Vioxx, but the end result and its associated healthcare system burden are the same…maybe even worse.

Highly addictive painkillers are at the heart of the growing trend of prescription medication abuse in Canada. A study published in the CMAJ several years ago noted that oxycodone prescriptions increased 850% from 1991-2007; and since the introduction of the longer-acting formulation of OxyContin, the researchers found a 5-fold increase in oxycodone-related mortality. Translation? We are on an exponentially rising trajectory in terms of OxyContin related deaths.

In addition, this is excluding the tremendous cost to the healthcare system when you factor in the ever growing numbers of addiction-related problems such as non-fatal overdoses, mental health illnesses, rehabilitation and other associated issues.

And OxyContin isn’t that perfect a painkiller. I have yet to come across a patient who reported “Wow, after taking that one OxyContin, my pain is gone forever!“. Like most opioids, pain is reduced to a varying degree – it almost never cures or “kills” the pain until the underlying etiology is treated. In fact, the norm is for patients to escalate their required dosing over time. And like Vioxx, OxyContin certainly doesn’t save any lives.

What we have then, is a “painkiller” that doesn’t truly cures pain, and is associated with rising mortality; so really, just a “killer“. Many health professionals would argue that the health benefits of pain control through OxyContin is far outweighed by the morbidity and mortality it causes on a population level.

My humble guess is that making a cheaper generic version available will not turn the tide.

The Health Minister’s stance, while disappointing to many health experts, is not entirely surprising. It really is just another example of our outdated and broken healthcare system:

Federal: “Here’s some $ for running your healthcare system, go to it.
Provinces: “But we need some guidance on these national health issues! Canadians deserve some national standards!
Federal: “Not my problem. The Health Act says the 13 of you have all the powers to run it how ever you like; we just give you the dough.
Provinces: “But what if we all come to different varying standards on a national health and safety issue that kills thousands of patients a year?
Federal: “Go regulate your doctors’ prescribing practices better.

Interestingly, the company that manufactured Vioxx (Merck) also used a similar line of argument for its defense against the onslaught of lawsuits that ensued. They argued that cardiovascular risks were mentioned in the product label, and it was up to prescribing physicians to dispense safely. If that was good enough, perhaps we should still be keeping Vioxx on the market … 60,000 deaths would argue otherwise.

What does it take before we get national leadership in healthcare? Does Health Canada not have a role in examining the risk/benefit ratios on a population level before allowing certain prescription medications on the market? Can we afford to keep passing on the responsibility to 13 fragmented pieces and call it a national Canadian healthcare system?

In the meantime, it seems like we may be creating another Vioxx-tale for future generations. Maybe they’ll listen.

Edmund Kwok

Edmund Kwok

Emergency Medicine. Quality Improvement. Patient Safety. Change Management. Healthcare Administration.

Frontdoor 2 Healthcare

Frontdoor2Healthcare, founded by Dr. Edmund Kwok in 2012, provides editorial and commentary on issues affecting Canadian healthcare from the emergency department’s “front door” perspective. Frontdoor posts allow for open sharing of the diverse opinions and perspectives of emergency physicians from across the country.

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