Clarification from the College of Physicians and Surgeons of BC on commentary about limitations of the CDC guideline for prescribing opioids

The college would like to address several inaccuracies in a commentary that appeared in CMAJ in December 2016.1

The following statement reflects confusion about two separate events:

There is already preliminary evidence that in British Columbia, where the CDC [US Centers for Disease Control and Prevention] guideline recommendations have been adopted as standards of practice, some patients have sought illicit opioids in the wake of reduced prescribing by physicians.

The college never “adopted” the CDC guideline2 as standards of practice. In April 2016, the college board “endorsed” the principles contained in it, and directed that the college review and update its own Prescribing Principles for Chronic Non-Cancer Pain based on the 12 recommendations contained in the CDC guideline.3

On June 1, 2016, the college board officially replaced Prescribing Principles with a new professional standard titled, Safe Prescribing of Drugs with Potential for Misuse/Diversion (www.cpsbc.ca/files/pdf/2016-06-01-Board-Adopts-New-Standard-on-Safe-Prescribing.pdf). Although many of the principles reflect the CDC guidelines, the college’s standard addresses broader issues of safe prescribing across many drug classes and diagnoses, not just opioids.

All of the principles contained in the standard were deliberately written in general terms, allowing flexibility so that physicians can use their own bedside clinical judgment, and determine the best course of action for their patients. Nothing in the standard prohibits — or even materially interferes with — the ability of pain specialists or other physicians to safely and effectively care for their patients. The standard reinforces the fact that physicians need to be accountable — both to the patient and society at large — for the prescriptions they write. The standard endorses an empathetic discussion between physician and patient of benefits versus harms of long-term prescription medications.

The college is unaware of any incident where a patient has sought illicit opioids as a result of a physician’s reduced prescribing, and suggests it is irresponsible of the authors to make such a claim and to reference a CBC News article as the source of this “preliminary evidence.” The standard does not direct that physicians refrain from prescribing opioids, or stop prescribing opioids immediately. Rather, it clearly guides physicians to taper opioids slowly, when appropriate, in order to minimize symptoms of withdrawal.

Although the college’s professional standard on safe prescribing is legally enforceable under the Health Professions Act, the college prefers to take a remedial approach if it has concerns about a physician’s prescribing patterns. No physician has ever been disciplined or fined for writing a prescription that exceeds a recommended dose. Now more than ever, physicians are being called upon to critically analyze their medication regimens for patients with chronic noncancer pain and other complex patients, and to exercise judicious, safe prescribing.