ON LONDON'S EAST SIDE, OXYCONTIN IS KING

Deb Matthews has seen the stats that show her province has the worst
rate of prescription-drug addiction in the country. And she's heard
the stories: northern cities fighting a losing battle, native
communities torn apart, small towns contending with thefts and
break-and-enters so residents can feed their habits.
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But Ontario's Health Minister doesn't need to go far afield to find
motivation for the policy response she's set to begin rolling out in
the coming weeks. She just has to wander a few blocks from her
constituency office.

The east side of London, Ont., has it bad. Along the main drag of
Dundas Street, there are drug houses, rehab centres, a disconcerting
number of young women working the street, and an equally
disconcerting number of young men wandering aimlessly.

A variety of poisons like crack and crystal meth are shared among
them. But OxyContin is king.

Listening to experts rhyme off the horror stories Families broken
apart! Hundreds of overdose deaths! Teenagers holding "pill
parties!" it can sound like the latest in a long line of drug
scares. Some social workers are quick to dismiss it as such,
suggesting the root causes don't change much with whatever narcotic
is in fashion. And indeed, many people are down and out before they
start self-medicating.

But there's something more going on here. Through over-prescribing,
the public-health system is actively, if inadvertently, creating
thousands upon thousands of drug addicts. And it's flooding the
streets with the pills to feed those addictions.

Laura wasn't yet 20, working as a landscaper, when she had surgery
for carpal tunnel in her hand. The doctor prescribed her Oxy.

Back then, she just popped the pills. Today, like most addicts, she
injects for a quicker and more direct fix not unlike heroin.

"I was somebody," she says, now 27 years old and working in London as
a prostitute. It doesn't come out ruefully more like she knows
she's reciting a cliche.

Laura (not her real name) smokes crack sometimes; it's her
boyfriend's drug of choice. But like an estimated 70 per cent of
local street prostitutes, she mostly uses a drug dispensed at
pharmacies. And even as she talks about the horrible crashes, the
judgment from passersby, her anger at the doctor she sees as
responsible for inadvertently hooking her, the abuse she's taken from
johns she knows she's a long way from escaping what began nearly a
decade ago.

"I fucking love Oxy," Laura says.

No easy solution

A lot of Ontarians feel the same way Laura does and it's only
recently that the government recognized it's a problem.

In fairness, everyone was caught off guard by the explosion of
OxyContin a slow-release form of the opioid oxycodone after it
hit the market in the 1990s. But some provinces have been quicker
than others to recognize that the highly addictive chronic-pain
reliever is widely abused, and moved to monitor and restrict the
amounts prescribed and dispensed.

"Ontario is doing worse on this front than any other province, by a
long shot," Ms. Matthews says during an interview in her riding. The
numbers speak for themselves: In 2008, OxyContin was sold by Ontario
pharmacies at more than double the national average.

In 2008-09, it accounted for 45 per cent of the staggering 3.6
million opioid prescriptions paid for by the Ontario Drug
Benefit the public plan that covers seniors and low-income
patients. (By 2009-10, the ODB was up to 3.9 million opioid claims,
made by 776,000 people.) It's not known how many more prescriptions
are sold to cash-paying customers or private plans.

Ms. Matthews, who first took an interest in the file during her
previous posting as minister of women's affairs and children's
services, knows that at this stage there's no easy solution.

Ontario officials reject the idea of banning the drug outright. They
don't even want to go as far as Manitoba, which recently began
requiring doctors to get approval from the provincial ministry before
writing an OxyContin prescription. They fear swinging the pendulum
too far in the other direction, because Oxy is very effective in
helping with pain that would otherwise be
unmanageable particularly, though not exclusively, for cancer sufferers.

So Ms. Matthews's aim is to strike a balance in which OxyContin only
winds up in the hands of the right people.

Multifacedted approach

In 2009, the province set up an advisory committee of doctors,
pharmacists, police, coroners and various other experts to develop a
multipronged strategy to curb prescription-drug addiction.

Ms. Matthews seems to think, or at least hope, that the biggest prong
can and should be education. Enlighten health professionals on what
they're dealing with, set clear guidelines for when and how much to
prescribe and dispense, then trust them to make the right decisions.

"My starting point is that the vast majority of doctors and
pharmacists want to do what's right for their patients," she says.
But some doctors "don't have the information they need to
appropriately prescribe" leading them to prescribe to people with
relatively mild pain that could be managed in other ways, or to write
overly large prescriptions.

But it's hard to believe that any physician is blissfully unaware
that it's a bad idea to prescribe hundreds of tablets at once, or
that a drug-abusing patient can't easily be identified as such. And
it's difficult to escape the fact that, in places such as London,
addicts are able to rhyme off which doctors will write prescriptions
without asking too many questions.

Ms. Matthews acknowledges that "a very few outliers might be
complicit in illegal activity." For others, it may be too difficult
to do the right thing addicts (or dealers) can be persistent, and
in some cases intimidating. The easiest thing could be to give them
what they want, especially if there's a sense that otherwise they'll
get it somewhere else.

The government's challenge, for all the talk of education, is largely
to set and enforce standards that place less onus on individual
doctors and pharmacists to make discretionary decisions about
prescribing and dispensing. In addition to limiting the number of
pills that can be prescribed at once, that will ultimately mean
taking measures to ensure patients can't shop around to multiple
doctors or get the same prescriptions filled at multiple pharmacies.
And at some point, it will require cracking down on doctors with
patterns of over-prescribing.

This would all be much easier if the province's efforts to create a
system of electronic health records hadn't been massively set back by
last year's eHealth Ontario scandal. In the meantime, the government
has ways of monitoring ODB prescriptions, at least, though addicts
can work around that by paying cash. The province will have to get
the support of private plans, and overcome sensitive privacy issues,
to monitor the rest.

It will be a slow build. Even Ms. Matthews bursts into laughter at
the notion of half the OxyContin being dispensed within a few years from now.

Dangers of restricting supply

But no matter how long it takes, there's an obvious question left
here: What happens if the province succeeds in lowering the supply of
the drug, but not the demand for it?

Put another way: What about all those addicts the system has already created?

Choking the supply might force a few to confront their addiction. But
more will just find another drug. Already, there are rumours of
heroin being introduced into the London market, possibly because even
now, there isn't quite enough Oxy to go around.

To the extent that Oxy is still available, reducing the supply will
put a premium on it. That could easily lead to more crime, not less.

"I think that's an issue to be aware of; I don't think it's a reason
not to do it," Ms. Matthews says. But, she acknowledges that
treatment as well as prevention will have to be part of the plan.

In London, an integrated addiction strategy seems to have strong
support from the municipal government as it strives to offer
everything from shelter to counselling to harm reduction. Still, many
of the people running those services complain bitterly about a lack
of federal and provincial support. Spots in rehabilitation clinics
are scarce. When they do come up for a spot in an overnight rehab
clinic, many addicts wind up passing them up because of a peculiar
rule that requires them to first be clean for 72 hours. And there are
the common complaints about a lack of adequate investment in mental
health services, as well as affordable housing.

As for Laura, she has every reason to want to get clean most
notably an infant daughter she's sent off to live with her family.
But she knows from past experience she got clean twice, only to get
sucked back in by her friends that it's more than she can manage right now.

Ms. Matthews doesn't have many answers for her. But for now, at
least, she'd settle for stopping more Lauras from finding their way
to the street.

This is the second instalment of a four-part series