We thank Dr. Oetter, Registrar and CEO of the College of Physicians and Surgeons of British Columbia, for her letter1 in response to our commentary.2
Contrary to her assertion that we “are making inaccurate assumptions about what regulators know and do,” we understand, and indeed expect, that colleges that regulate physicians will operate within their mandates; observe core values, such as accountability, justice, integrity and collaboration; and practice evidence-informed health policy. Colleges that fail to observe these principles undermine their own credibility as regulatory authorities.
The 2017 Canadian “Guideline for Opioid Therapy and Chronic Noncancer Pain”3 provides recommendations based on the best available evidence where possible, and where evidence is conflicting or absent, it provides best practice and expert guidance statements. The authors of the guideline explicitly stated that qualifying remarks and values and preferences should never be omitted when quoting or translating recommendations contained within the guideline. They also stated that strong recommendations represent candidates for quality-of-care criteria or performance indicators, whereas weak recommendations should not be used as a basis for standards of practice (other than to mandate shared decision-making). Policy-making based on weak recommendations, and best practice and expert guidance statements will require substantial debate and involvement of various stakeholders.
The authors of the new guideline3 found no evidence of differences in the effectiveness of opioids across clinical conditions, meaning that all patients with chronic noncancer pain should be treated equally. We are, therefore, reassured by Dr. Oetter’s statement that regulators are very firm about prohibiting discrimination on the basis of medical condition.
We look forward to colleges rescinding any statements in their policies that might discriminate against patients with certain conditions, such as headache disorders, fibromyalgia and axial low-back pain.
We understand that the role of colleges is to protect patients and the public at large; however, legally enforceable policies, developed without regard to the best available evidence and its limitations, and without input from all stakeholder groups, may lead to unintended adverse outcomes in the people they aim to protect.
Therefore, we hope that regulators will collaborate with representatives of the one in five Canadians living with persistent pain and the physicians who care for them, when developing policy based on the new guideline.
Footnotes
Competing interests: Owen Williamson reports nonfinancial support from Health Canada, and personal fees and nonfinancial support from Purdue Pharma (Canada), Mundipharma International Ltd. and INVIVO Communications Ltd., outside the submitted work. Andrea Furlan is acknowledged in the 2017 “Guideline for Opioid Therapy and Chronic Noncancer Pain.” She participated in the first meeting of the clinical experts in January 2016 but was not involved in the remaining development of the guideline.