Before fentanyl became the latest villain in a full-blown overdose crisis in Canada, Kelly Lanktree was in need of something to numb the excruciating pain in her knee.
She had tumbled down stairs at work in 2009 and her doctor steered her towards OxyContin. The drug, she found, was not only effective at treating her physical pain, but also at temporarily freeing her of her emotional issues built up after years of abuse.
That feeling of relief was addictive for Lanktree, who slowly upped her own dose — taking a couple of extra pills here and there at first, then chewing, crushing, and snorting them, and eventually injecting the drug. Her own prescription was supplemented by that of her husband, who'd also been given a script for OxyContin but at a higher dose.
"My doctor prescribed [the painkillers] pretty much like candy," she said. "There were never any questions."
OxyContin was removed from the shelves in 2012, replaced by a supposedly tamper-resistant version. In its stead, fentanyl stepped in. In just a few short years, the drug has become a household name among Canadians, with health authorities scrambling to get a grip on the country-wide crisis caused by the powerful opioid.
The rise of fentanyl can be traced back to doctors' offices, according to leading researchers and doctors who blame several decades of liberally prescribing highly potent opioids to patients who shouldn't have been exposed to them in the first place for creating a huge market for the organized crime groups, who are now exploiting a population of opioid misusers.
"Organized crime groups have ... moved in because it's now very lucrative," said Dr. Keith Ahamad, a clinician at the B.C. Centre for Excellence in HIV/AIDS. "The origin of the problem absolutely comes from doctors' prescription pads. We've created this cohort of people who are physically dependent and addicted to these medications, and now they're looking for them in the black market, but it's not the same drug."
"These people who are looking for oxycodone, which they were using before ... but it's been replaced by illegal fentanyl," he explained.
David Juurlink head of clinical pharmacology and toxicology at Toronto's Sunnybrook Health Sciences Centre agrees the relationship between the rise in fentanyl overdoses and how doctors have been prescribing opioids is a direct one.
"Sometimes, those are people who began as patients and fell into addiction. Quite often, they're people who began simply experimenting with drugs that were prescribed to somebody else," he said. "But these drugs can get a grip on a person very quickly, and at some point, your drug coverage ceases or your ability to pay for the drugs ceases, and you begin to find them on the street."
Overdoses involving fentanyl combined with other drugs, like heroin, or cases in which fentanyl is mistaken for other opioids, like OxyContin, are also common.
"There are people out there who will buy these pills," Juurlink said. "They have no clue what they're getting, and that's why people are dying."
North Americans consume about 80 percent of the world's prescription opioids and Canada is one of the highest per capita consumers, behind only the United States, according to the International Narcotics Control Board. Further, according to Dr. Benedikt Fischer of the Centre for Addiction and Mental Health, Canada prescribes four times more fentanyl than the US.
Researchers say the scientific evidence for long-term use of opioids for chronic pain is scarce. Yet we've seen the number of people with such prescriptions increase significantly over the past 20 years, just as the harms associated with them, like overdose and addiction, have become more obvious.
A University of British Columbia study published in November of last year, for example, found that there was a correlation between the rate of prescription opioids across the provinces and the number of opioid-related deaths.
And for many of those who began their addiction under a doctor's supervision, the habit is hard to kick.
For almost a year, Lanktree said was a functioning addict, yet still managed to keep up with work, family, and friends.
"But once I started getting into injecting and using even more than I was being prescribed, I started having to purchase extra on the side, on the street, and that started eating into every bit of money I had," she recalled. She and her husband would go on to sell anything of value around their house, eventually selling even their wedding bands to support their habit.
Unable to pay rent, the couple ended up at her parents' house, and soon after, on the streets.
Lanktree said that while her problem was obvious to everyone else in her life, her doctor would barely look up from his computer long enough to notice anything was wrong.
"I was wearing gloves on my hands in the middle of the summer to try and cover up track marks, long sleeves, and constantly scheduling appointments right when our script was due or cancelling and [asking the doctor], 'Can you just call it in?'"
Researchers began developing longer-acting opioids to treat chronic pain in cancer patients in the 1980s, with products like methadone, oxycodone, hydromorphone, and fentanyl becoming more and more popular with doctors and patients because they were more potent and better absorbed than morphine.
Then came an endorsement from the World Health Organization, which recommended in 1986 that potent opioids be used as an initial treatment for moderate to severe cancer pain relief, followed by a push from researchers, doctors, and the pharmaceutical industry for the use of oral opioids for non-cancer pain.
"No one went to jail, of course. You only go to jail for selling cannabis."
"Although not supported by strong evidence, this practice spread and drove a worldwide surge in prescription and consumption of oral opioids over the last 20 years," said a 2015 report by the Canadian Network for Observational Drug Effect Studies.
In 2011, Canada and the US.'s consumption rates both doubled the average rates of the European Union, Australia and New Zealand. According to the CNODES report, Canada's rate of opioid drug consumption ranks second behind only the United States.
"It probably comes from the fact that many of these pharmaceutical companies are North American, and in the late 90s, they marketed to physicians who were struggling to find treatment for patients who had chronic pain," Ahamad explained. "Really, this has come out of a place where doctors were trying to help a patient population that was suffering, and it got exploited."
Ahamad says along with a lack of education on the part of medical professionals on how to use opioids properly, there's also little support for non-pharmacological treatment of pain methods like cognitive behavioural therapy and physiotherapy, which aren't covered by most drug plans — unlike opioids, including fentanyl.
David Juurlink, head of clinical pharmacology and toxicology at Toronto's Sunnybrook Health Sciences Centre, points to the aggressive marketing of OcyContin in the 1990s as a turning point in how opioids have come to be used.
"We operate this way because we were taught by the pharmaceutical companies that make these drugs and key opinion leader physicians, who effectively served as their agents, to do so based upon evidence that was either flimsy or non-existent," he said.
OxyContin, which was taken off Canadian shelves in 2012, and replaced with a tamper-resistant version of oxycodone called OxyNeo, was for many years immensely popular among chronic pain patients, and being prone to abuse, among non-prescription users.
Three executives with the American branch of Purdue Pharma, the makers of OxyContin, pled guilty in 2007 to misleading regulators and the public about risk of addiction associated with the drug, and the company agreed to pay over $600 in fines.
After it was approved by the Food and Drug Administration in 1995, the company launched an unprecedented marketing push behind the drug. It included, among other things, recruiting and training thousands of doctors, pharmacists, and nurses to promote it, giving substantial bonuses to sales reps, and distributing OxyContin-branded swag to health care professionals.
"No one went to jail, of course," remarked Juurlink. "You only go to jail for selling cannabis."
The practice of prescribing opioids for chronic pain was quickly adopted by physicians, who bought into the campaign.
"When you reflect on that, it's easy to understand why they did," said Juurlink. "We want to help people, and we are conditioned to intervene, so when we went to these sessions and were told by articulate and clearly well-meaning people that we could use opioids safely, that the risk of addiction was low, that was the sort of message we were happy to hear and we began using these drugs liberally."
A societal expectation that there will be a pill for every problem is also partly to blame of the problem, Juurlink said.
"A quick fix is very appealing to the North American society," he said. "Doctors, in this instance, obliged patients because we were told we could do so safely and effectively."
While Canada has more control over how pharmaceutical products are promoted to the public than the US, its overall consumption patterns are quickly approaching those of its neighbor to the south.
For example, from 2006 to 2011, the prescription of high dose opioid formulations went up by 23 percent, according to a 2014 study published in the Canadian Family Physician.
And as opioid consumption has risen, opioid-related deaths have mirrored the trend — although no national statistics are available, provincial numbers shed some light on the trend. In three Canadian provinces and a handful of American states for which there is data shows, the overdose rate associated with fentanyl has skyrocketed in recent years, by factors of 200 percent and more.
A study released in April by the University of Manitoba, which found that while patients are supposed to have had some experience with opioids before being prescribed fentanyl, that wasn't happening in half of the cases they studied. That raised concerns about the cavalier way in which doctors have been prescribing them, experts say.
"Ensuring adequate opioid tolerance before prescribing a fentanyl patch is one measure that is fully in the hands of physicians and pharmacists," co-author Shawn Bugden had said in a press release about the study.
Most in the medical community agree that there's a place for opioids in the treatment of pain. In some cases, their benefits are undeniable.
"But we need to invest in non-medication related treatment for chronic pain, but right now, it's just not available," said Ahamad, who believes a comprehensive response, including training family doctors to diagnose and treat addiction in an evidence-based way and support for harm reduction programs, is necessary.
Ahamad also said suboxone and methadone, drugs used to treat opioid addiction, should be available in primary care settings across the country, and that doctors should be trained in how to prescribe it.
Lanktree considers herself lucky for being able to get on a methadone treatment program right away, having "failed miserably" at abstinence-based rehab earlier.
"Once I was on the street, I got to speaking with more people who were involved in drugs, who had used opiates, who had been down multiple treatment paths," she recalled. A friend pushed her to try methadone.
"Just a few weeks into treatment, I started noticing a clearheadedness I hadn't had in years. I no longer needed to use nearly as much. My cravings weren't as bad. Eventually, I was able to completely stop injecting altogether," she said. "And I've been doing great ever since."