New Canadian guidance on opioid use for chronic pain: necessary but not sufficient

In their commentary, while appropriately advocating for increased resources to assist people living with chronic pain, Drs. Furlan and Williamson assert that regulators will "... need to be made aware that there is a small but definite role for the use of opioids in managing chronic non-cancer pain, and that over-regulating prescribers so they cannot undertake trials of safe and effective therapies would be unhelpful."

To be clear, medical regulators have never denied a "small but definite role" for opioids, nor interfered with competently conducted trials of therapy.

In our experience, patients often over-value opioids, benzodiazepines, anticonvulsants and other medications commonly used in this context. Physicians are naturally affected by their patients' suffering and may feel compelled to accede to demands for medically inappropriate prescribing. Accordingly, safe prescribing for chronic non- cancer pain is among the most challenging aspects of medical practice for patients and physicians alike. The large majority of physicians are grateful for some assistance.

Many physicians adopted a more liberal approach to prescribing opioids and other potentially addictive drugs for chronic pain in the 1990s because, based largely on gratifying experience with palliative care and gross underestimates of the risk of addiction, they anticipated it would be both safe and effective.

About 15 years ago, medical regulators were among the first to recognize and respond to emerging harms. The 2010 Canadian Guideline was initiated and funded by medical regulators. Since that time, the College of Physicians and Surgeons of BC has worked with hundreds of registrants through various means (e.g. published policies and resources, telephone advice, correspondence, face-to-face reviews of prescribing profiles, and educational events, both plenary and limited-enrollment, in-house and in collaboration) to help them operationalize foundational principles most recently set out in a professional standard, Safe Prescribing for Drugs with Potential for Misuse/Diversion.

Chronic pain and addiction are both medical conditions. The CMA Code of Ethics prohibits discrimination on the basis of medical condition, and regulators are very firm about asserting this obligation in communication with physicians.

The College of Physicians and Surgeons of BC receives complaints and reports reflecting various perspectives from patients, concerned family members, other physicians, pharmacists, coroners, social workers, insurers and law enforcement. In the past 25 years, none has been brought to discipline in BC. Physicians want to provide safe and effective care, which they owe to their patients. The College has no mandate or desire to punish them for that; and in fact, has a shared interest in helping them acquire the skill and knowledge they require to prescribe safely.

The characterization of regulation reflected in this commentary suggests that the authors are making inaccurate assumptions about what regulators know and do. Developing standards and guidelines for safe prescribing is assuredly not "over-regulation." This College has welcomed the new Canadian Guideline for Opioid Therapy and Chronic Non-cancer Pain, which affirms and complements other policies and will assist us in our work with physicians (though we are disappointed that the guideline fails to highlight the serious, entirely-avoidable risk associated with combining opioids with benzodiazepines, and other sedatives). The goal has never been to prohibit opioid therapy, only to make it safer. Our observation is that virtually every primary care physician continues to recognize the "small but definite role" in their practice.

H.M. Oetter, MD Registrar and CEO

Cc. Andrea Furlan at andrea.furlan@uhn.ca

Conflict of Interest:

None declared