Many prescription opioid addicts engage in 'doctor shopping' before overdose deaths

When Jordan Miller died from an opioid overdose, it wasn't from fentanyl or another substance he had bought on the street — it was from legally prescribed drugs he had obtained after visiting several different doctors.

The source of the drugs he took is far more common than most would imagine. New Alberta figures show nearly 40 per cent of those dying from an overdose had been prescribed opioids by at least three different doctors in the year before they died.

While the opioid crisis is often perceived as one involving street drugs manufactured in clandestine labs, many in the medical community are awakening to the role of physicians who inadvertently create addicts through the liberal prescribing of painkillers such as oxycodone.

The problem is that when prescriptions run out, the dependence on drugs can remain, driving once-productive citizens to scour the streets for illicit substitutes or to go "doctor shopping," where they approach multiple doctors in search of a new prescription.

That's the path that led Miller, a happy-go-lucky young man who owned his own business at age 22, to become another name on a sad list of lost sons and daughters three years later.

Miller was prescribed oxycodone after hurting his back in a construction accident. After months of taking the drug, his mother became concerned about addiction and spoke to their doctor. 

Jordan's prescriptions were cut off. He did a stint in rehab, but after a couple of months the need for opioids grew too strong for him to resist. His mother, Leslie McBain, believes he was receiving prescriptions for various forms of opioid-based drugs from as many as five physicians.

"He was able to cobble together enough opioids by doctor shopping to not withdraw, not go into withdrawal," says McBain. "Unfortunately the combination of the drugs that he had was lethal."

New guidelines on opioid prescription

When OxyContin hit the market in 1996, it was heavily promoted by its manufacturer Purdue Pharma and became widely used. 

While the original brand of the drug is no longer being sold, several other opioid-based treatments are now available. In Canada last year those drugs accounted for more than 30 million prescriptions valued at $881 million, according to QuintilesIMS, which tracks pharmaceutical sales.

"I think that the marketing efforts, perhaps an inappropriate understanding of the associated harms and the real need to try to provide options for patients with chronic pain all came together to result in quite a bit of opioid prescribing that increased over time," says Dr. Jason Busse of McMaster University, who is chairing a panel of experts developing new national guidelines on prescribing the drugs.

Among the new guidelines being proposed:

• Limiting intake to 50 mg morphine equivalents daily, with an upper limit of 90 mg. Currently there is no upper limit and some patients are prescribed over 200 mg.
• Not recommending opioids for patients with active substance abuse disorders. 
• Tapering opioids to the lowest possible dose, including discontinuation.

Busse, who works with the Michael G. DeGroot National Pain Centre in Hamilton, also sees potential peril in efforts to wean Canadians off powerful pain medication.

"If they are taken off their opioids too quickly, if they are tapered aggressively, it is likely that a number of individuals will go into opioid withdrawal. And these symptoms can be extremely troubling."

Western provinces developing strategies

Alberta and B.C. have been hardest hit with opioid overdoses so far, with a combined 1,257 deaths in 2016. The actual number is likely higher, as Alberta only includes fentanyl deaths in its total, excluding those who died taking prescribed painkillers.

B.C. has already introduced new measures to control how opioids are prescribed. Among the changes the B.C. College of Physicians and Surgeons recommends are the same dosing levels suggested for national guidelines. The college also wants doctors to review a patient's medication history before writing a prescription, in order to avoid the doctor shopping that led to Miller's death.

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Alberta's College of Physicians and Surgeons expects new guidelines to be in place next month. They are currently being reviewed.

Kelly Eby, the college's spokeswoman, says doctors will be asked to consider options other than opioid drugs for new patients, and tapering down the dosage for those who are able.

But the guidelines also leave some discretion to physicians.

"The way the draft standard is currently written is that these are the things that we are asking physicians to be aware of and follow in regards to rules," Eby says, "but if you're not following, for example the maximum dosage or maximum required dosage, we need to be able to, the physician needs to be able to justify why they're not."

Doctors sanctioned

Following the death of her son, McBain filed a complaint with the B.C. College of Physicians and Surgeons. She says it resulted in two of the doctors who wrote prescriptions for her son being sanctioned.

She believes that if doctors had reviewed his history before writing out scripts, he could still be alive today. And while she's pleased that the tracking of prescriptions is now mandated in B.C., she believes the policy still isn't being followed by doctors in all cases.

In the meantime, she is grieving the loss of her only son by making it a mission to save the children of other families. As co-founder of Moms Stop the Harm, she is now advocating for tougher rules around prescribing and improved options for treatment.