Opioids and chronic pain
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* Meldon M. Kahan

MacDonald and colleagues suggest that physicians are reluctant to prescribe opioids because of fears about addiction.1 Evidence suggests otherwise. Canada and the United States are the biggest consumers of opioids in the world.2 Canadian per-capita opioid consumption more than doubled from 1997 to 2006, and consumption of oxycodone climbed rapidly from 2007 to 2010.2 In a recent random survey of Ontario family physicians, over 95% of respondents reported prescribing opioids for chronic pain within the last three months; only 1.4% reported not prescribing because of concerns about opioid addiction.3

The authors dismiss concerns about opioids as “frequently exaggerated” and fail to mention the serious and growing public harms. In 2006 in Ontario, 423 people died from an opioid overdose — far fewer deaths were attributed to HIV that year.4 In the US, opioid overdose is the second most common cause of death in men aged 35–54 years.2 Admissions for prescription opioid addiction treatment have increased substantially in the last 10 years.5

This should concern the entire medical community. Physicians’ prescriptions are a major source of the opioids used by addicted patients and overdose victims,4 and the risk of overdose is strongly associated with the dose of opioid prescribed.6

To resolve the opioid crisis, family physicians and pain specialists must first recognize that, while opioids have an important role in pain management, they can be dangerous when prescribed to the wrong patient or at the wrong dose. A comprehensive educational strategy is needed to give physicians the skills to prescribe opioids safely and to manage the care of patients who are already addicted or taking high doses.

## References

1.  MacDonald NE, Flegel K, Hébert PC. Better management of chronic pain care for all [editorial]. CMAJ 2011;183:1815.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTgzLzE2LzE4MTUiO3M6NDoiYXRvbSI7czoyMToiL2NtYWovMTg0LzEvNzQuMS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

2.  Fischer B, Jones W, Murray K, et al. Differences and over-time changes in levels of prescription opioid analgesic dispensing from retail pharmacies in Canada, 2005–2010. Pharmacoepidemiol Drug Saf 2011;20:1269–77.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1002/pds.2190&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=21755568&link_type=MED&atom=%2Fcmaj%2F184%2F1%2F74.1.atom) 

3.  Wenghofer EF, Wilson L, Kahan M, et al. Survey of Ontario primary care physicians’ experiences with opioid prescribing. Can Fam Physician 2011; 57:324–32.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiY2ZwIjtzOjU6InJlc2lkIjtzOjg6IjU3LzMvMzI0IjtzOjQ6ImF0b20iO3M6MjE6Ii9jbWFqLzE4NC8xLzc0LjEuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

4.  Dhalla IA, Mamdani MM, Sivilotti ML, et al. Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone. CMAJ 2009;181:891–6.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMDoiMTgxLzEyLzg5MSI7czo0OiJhdG9tIjtzOjIxOiIvY21hai8xODQvMS83NC4xLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

5.  Fischer B, Nakamura N, Rush B, et al. Changes in and characteristics of admissions to treatment related to problematic prescription opioid use in Ontario, 2004–2009. Drug Alcohol Depend 2010; 109:257–60.
    
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    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=20197216&link_type=MED&atom=%2Fcmaj%2F184%2F1%2F74.1.atom) 

6.  Gomes T, Mamdani MM, Dhalla IA, et al. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med 2011;171: 686–91.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1001/archinternmed.2011.117&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=21482846&link_type=MED&atom=%2Fcmaj%2F184%2F1%2F74.1.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000289867700017&link_type=ISI)