Tackling drug toxicity crisis requires collaboration at local and international levels

With International Overdose Awareness Day on August 31, new research examines accountability for initiating events of current drug toxicity crisis and sheds light on importance of primary care for people with opioid use disorder

Many families across Ontario know the devastation caused by the opioid and toxic drug crisis. According to the Ontario Drug Policy Research Network (ODPRN), this year an average of four people in Ontario die every day from suspected opioid toxicity.

“It’s important to remember that these aren't just statistics, these are people. Every number is a person and a life, with loved ones and family who are left behind,” says Jillian Kohler, professor at the Leslie Dan Faculty of Pharmacy. “This is a global health issue that goes beyond opioids and includes a toxic, unregulated drug supply and dangerous combinations of drugs. It is a public health crisis.”

Kohler’s research program at the Leslie Dan Faculty of Pharmacy focuses on anti-corruption, transparency and accountability in the pharmaceutical sector. Part of her work in recent years has been examining policies related to opioids and access to essential medications globally. She and her team contributed to a recently published World Health Organization guideline on how countries can develop controlled medicines policies, such as opioid policies, to balance access and safety.

Kohler and members of her team, including former PhD student Andrea Bowra, have also applied their expertise in accountability to examine the initial events that led to the current drug toxicity crisis. By understanding the origins of the current crisis and whether the actors involved were held accountable, they hope to learn how global organizations and pharmaceutical manufacturers can balance access to medications and public safety.

“There's so many advances and important medical kind of inventions that come out of the pharmaceutical industry, including pain relief, but research like this shows that there needs to be equitable access and balance,” says Bowra, now a post-doctoral fellow at Humber River Health. “We need to make sure that there is equitable access globally, but that we are also safeguarding public health against for-profit interests and not causing harm through actions like inappropriate marketing.”

Grassroots movements held opioid manufacturer accountable for misleading marketing

Previous research has established that in the mid-1990s, Purdue Pharmaceuticals, the pharmaceutical company that manufactured the opioid OxyContin (oxycodone), knowingly disseminated misleading marketing about the drug, describing it as a non-addictive opioid that could be used to treat all kinds of pain. Through the company’s influence in health care sectors, the drug was overprescribed, contributing to many people becoming dependent on opioids. The overprescription of oxycodone has since ballooned into a far-reaching crisis with people being harmed by toxic supplies of drugs such as fentanyl and dangerous combinations of drugs.

During Bowra’s PhD research, she interviewed experts from a range of fields, including health care, law, the pharmaceutical industry and regulators to understand how accountability is enacted globally, specifically in the case of Purdue. The results were recently published in Globalization and Health.

The interviews suggested that the company and owners were held accountable through means such as social consequences such as ostracization, U.S. congressional hearings, and civil court cases, largely as a result of efforts by activist groups and investigative journalists. Bowra’s research also suggested that more safeguards and regulations are necessary to prevent large corporations from exerting the same influence that Purdue was able to in its marketing of OxyContin.

“There was a hopeful element in that civil society was able to enact some forms of accountability and hold a large corporation, which can seem untouchable, to account. These grassroots movements are an important way for change to take place,” says Bowra. “We need safeguards in place that regulate the industry’s influence in the health care system, and ensure that our governments, legal systems and health care systems can protect and prioritize public health.”

Kohler adds that tackling the current toxic drug crisis and preventing similar tragedies in the future requires many sectors and countries to work together.

“Having effective regulation is so important, and that requires thoughtful policies, laws, regulations and implementation, as well as effective monitoring and supervision,” says Kohler.  “There are no quick fixes. Tackling a complicated, global issue like this is not something that pharmacists, primary care or law enforcement can deal with on their own. This issue demands multi-sector and international cooperation.”

Primary care improves access to treatment following overdose

As action has been taken to hold Purdue accountable, the fallout from its actions is still being felt in communities and families across North America. Research from the ODPRN says that in Ontario from 2014 to 2021, there were more than 80,000 overdoses, of which nearly 70,000 were non-fatal. What happens next for those who survive?

Shaleesa Ledlie, a recent PhD graduate in pharmaceutical sciences at the Leslie Dan Faculty of Pharmacy supervised by Associate Professor (Status) Tara Gomes, recently published research that examined whether people with opioid use disorder who had been hospitalized for an opioid overdose were connected to treatment following discharge and the factors that increase the likelihood of treatment initiation.

Her research found that of the more than 13,000 people with opioid use disorder who experienced an overdose, only 10% started opioid agonist treatment or safer opioid supply, and one third had a follow-up visit with a primary care provider in the month following the overdose – suggesting that there are significant gaps in the pathway from hospital to community-based treatment. However, people who had primary care doctor and a high frequency of prior visits to their doctor had a higher likelihood of starting treatment and accessing primary care.

“Access to primary care plays a critical role in supporting individuals after an overdose. Our study highlights the importance of not just having access to primary care, but also building positive patient-provider relationships that encourages ongoing engagement with the health care system,” says Ledlie, currently a senior research associate at the ODPRN at Unity Health Toronto.

“Pharmacists also play an important role given that most people receive their opioid agonist treatment through community pharmacies on a daily basis. This creates a unique opportunity for pharmacists to provide consistent, non-stigmatizing care and build meaningful relationships, especially for people who may be largely disconnected from other forms of primary care.”

The study revealed hospital, geographic and individual factors that influence whether people access treatment after an overdose. And Ledlie says she hopes that a better understanding of these factors will improve access and reduce barriers to treatment, and ultimately improve outcomes for people with opioid use disorder.

“Findings from our study help can inform policies that improve how people who use drugs are connected to care after an overdose and highlight opportunities to improve coordination of care at various system and individual levels. For example, implementing targeted interventions like harm reduction and peer support in hospital can help people stay longer to complete necessary care and improve connection to outpatient services,” says Ledlie.

“I hope that this work supports policies that strengthen care pathways between emergency, hospital and community-based care, ultimately reducing overdose risk and improving health outcomes.”