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This marks a new low in the discussion of the so-called perils of therapeutic opiates. The authors advise Ottawa to recall "high dose" formulations of medical opiates. But what constitutes a "high" dose, when opiate dosing is properly done on a customized basis?
Whatever "high" means here, recent research suggests, not for the first time, that lower, not higher, doses wreak greater harm (https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2018.304590?journ...). In an open letter he signed last week disparaging forced tapering (https://academic.oup.com/painmedicine/advance-article/doi/10.1093/pm/pny...), Dr Juurlink himself acknowledges this.
Research also shows that prescribed opiates are not particularly lethal at any dose. The largest study to date, of nearly 2.2M Americans, pegs the annual overdose death rate from prescribed opiates at a mere 0.022% (https://academic.oup.com/painmedicine/article/17/1/85/1752837).
Truly confounding and downright weird is the authors' claim that more is less: that, say, two 50 mcg patches of transdermal fentanyl are safer than one 100 mcg patch. They're not, of course. "Pill burden"---making patients take a bunch of pills instead of one---is not a "relatively minor inconvenience"; it's trouble. The fewer pills or patches you use to achieve a dose, the more likely you are to get your dose right. Dr Juurlink, a pharmacist, doesn't seem to know that, nor does he seem to know or care that lower-dose formulations used in multiples cost patients more. That matters, since many Canadians with chronic pain don't have jobs with insurance plans and aren't living large on their disability pensions. What the authors are actually saying is that lower-dose formulations can be weaponized against users when they're employed to prompt patients to taper or end their therapy.
Whatever we think of the laundry list of "harms" the authors cite, we should be asking every time we hear it---and we hear it frequently---why physical dependence is bad when it involves medical opiates but not when it involves the many other drugs we become dependent on. Note, too, the judicious use of "likely" throughout the piece; it's a proxy for proof. Three of the six papers on opiates the authors cite are Dr Juurlink's own work. Two come from his compatriots. How do we know, then, beyond Dr Juurlink, that these "harms" are dose-dependent?
Moreover, there's plenty of evidence that doses of 200 to 400 MME afford more benefit than harm, as the AMA told us last month (https://www.cato.org/blog/better-late-never-0). Conversely, there's no evidence, as claimed here, that doses are continually escalated in patients with chronic pain. To the contrary, when effective doses are reached, they plateau.
But why should we restrict medically-managed opiates at all, when coroners' reports and the RCMP tell us repeatedly that it's not the medical supply but rather Chinese crime rings that are causing our overdose deaths? That's the evidence we should be looking at. Herder and Juurlink are emperors with no clothes, and it's time we stood up and said so.