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Commentary

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

Andrea D. Furlan and Owen D. Williamson
CMAJ May 08, 2017 189 (18) E650-E651; DOI: https://doi.org/10.1503/cmaj.170431
Andrea D. Furlan
Toronto Rehabilitation Institute (Furlan), University Health Network; Institute for Work and Health (Furlan); Department of Medicine (Furlan), University of Toronto, Toronto, Ont.; Department of Epidemiology and Preventive Medicine (Williamson), Monash University, Melbourne, Australia; Pain Management Clinic (Williamson), Fraser Health Authority, Surrey, BC
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  • For correspondence: andrea.furlan@uhn.ca
Owen D. Williamson
Toronto Rehabilitation Institute (Furlan), University Health Network; Institute for Work and Health (Furlan); Department of Medicine (Furlan), University of Toronto, Toronto, Ont.; Department of Epidemiology and Preventive Medicine (Williamson), Monash University, Melbourne, Australia; Pain Management Clinic (Williamson), Fraser Health Authority, Surrey, BC
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  • Re:Re: Commentary in volume 189, issue 18 - New Canadian guidance on opioid use for chronic pain: necessary but not sufficient, Andrea D. Furlan MD PhD, Owen D. Williamson MBBS
    Andrea D. Furlan
    Posted on: 31 May 2017
  • Sensible approaches to manage current opioid crisis
    Ediriweera Desapriya
    Posted on: 18 May 2017
  • Re:Re: Commentary in volume 189, issue 18 - New Canadian guidance on opioid use for chronic pain: necessary but not sufficient, Andrea D. Furlan MD PhD, Owen D. Williamson MBBS
    Ellen N Thompson MB BS, FRCPC
    Posted on: 16 May 2017
  • Re: Commentary in volume 189, issue 18 - New Canadian guidance on opioid use for chronic pain: necessary but not sufficient, Andrea D. Furlan MD PhD, Owen D. Williamson MBBS
    Heidi M. Oetter
    Posted on: 10 May 2017
  • Posted on: (31 May 2017)
    Page navigation anchor for Re:Re: Commentary in volume 189, issue 18 - New Canadian guidance on opioid use for chronic pain: necessary but not sufficient, Andrea D. Furlan MD PhD, Owen D. Williamson MBBS
    Re:Re: Commentary in volume 189, issue 18 - New Canadian guidance on opioid use for chronic pain: necessary but not sufficient, Andrea D. Furlan MD PhD, Owen D. Williamson MBBS
    • Andrea D. Furlan
    • Other Contributors:

    We thank Dr. Oetter, Registrar and CEO of the College of Physicians and Surgeons of British Columbia, for her response to our commentary.

    Contrary to her assertion that we "are making inaccurate assumptions about what regulators know and do", we understand, indeed expect, that Colleges that regulate physicians will operate within their mandates, observe core values, such as accountability, justice, integrity and...

    Show More

    We thank Dr. Oetter, Registrar and CEO of the College of Physicians and Surgeons of British Columbia, for her response to our commentary.

    Contrary to her assertion that we "are making inaccurate assumptions about what regulators know and do", we understand, 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 Use for Chronic Non-Cancer Pain provides recommendations based on the best available evidence where possible, and where evidence is conflicting or absence provides best practice and expert guidance statements. The authors of the guideline explicitly state that qualifying remarks and values and preferences should never be omitted when quoting or translating recommendations contained within the guidelines. They state that strong recommendations represent candidates for quality of care criteria or performance indicators, while weak recommendations should not be used as a basis for Standards of Practice (other than to mandate shared decision-making). Policymaking 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 guideline found no evidence of differences in the effectiveness of opioids across clinical conditions, meaning that all patients with chronic non-cancer 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 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.

    We therefore 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 guidelines.

    Conflict of Interest:

    Competing interests are listed in our Commentary: Can. Med. Assoc. J. 2017 189:E650-E651; doi:10.1503/cmaj.170431

    Show Less
    Competing Interests: None declared.
  • Posted on: (18 May 2017)
    Page navigation anchor for Sensible approaches to manage current opioid crisis
    Sensible approaches to manage current opioid crisis
    • Ediriweera Desapriya, Research Associate
    • Other Contributors:

    We believe that this is a complex health care issue and merely bringing a clinical guidelines alone would not work and there is a urgent need for a sensible overall approach to this problem: (1). Prescription narcotics ads in highly reputable medical journals need to stop immediately.

    (2). Highly publicized media campaign to highlight that the evidence for the benefits of opioids for long-term use is utterly ins...

    Show More

    We believe that this is a complex health care issue and merely bringing a clinical guidelines alone would not work and there is a urgent need for a sensible overall approach to this problem: (1). Prescription narcotics ads in highly reputable medical journals need to stop immediately.

    (2). Highly publicized media campaign to highlight that the evidence for the benefits of opioids for long-term use is utterly insufficient. (We should target both doctors and the patient community here)

    (3). When not prescribing opioids unnecessarily and irresponsibly, it is expected that the patients may very well write a bad review on responsible doctors. We need to develop some tools for doctors on how to manage their online reputation, despite unfairly written reviews for their responsible behavior.

    (4). Online education course to further improve effective communication skills of doctors on how to say "no" without upsetting the patient and more importantly without harming the doctor patient relationship. In addition, proposed online education course need to teach doctors how to manage their daily busy schedule and allocate a reasonable time to explain patient on known short term and long term side effects and highly addictive properties of opioids.

    (5). It is high time that educate doctors on promising alternative therapies on pain management. We need to think seriously that it is time to address the pain management with collaborative team approach: ED physicians and family doctors need to have access to a effective platform that facilitate frequent, open and regular conversation with pain specialists, physical therapists, chiropractors, acupuncturists, massage therapists, mental-health providers and addiction specialists. If this is feasible, it won't be impossible to find best solution for opioid crisis in Canada.

    (6). Current health insurance system is also part of the problem and we need to think seriously and bring sensible changes to the coverage including extended coverage for promising alternative pain management therapies.

    (7). Bring sensible changes to current weak and ineffective approaches to control illegal drugs.

    Conflict of Interest:

    N/A

    Show Less
    Competing Interests: None declared.
  • Posted on: (16 May 2017)
    Page navigation anchor for Re:Re: Commentary in volume 189, issue 18 - New Canadian guidance on opioid use for chronic pain: necessary but not sufficient, Andrea D. Furlan MD PhD, Owen D. Williamson MBBS
    Re:Re: Commentary in volume 189, issue 18 - New Canadian guidance on opioid use for chronic pain: necessary but not sufficient, Andrea D. Furlan MD PhD, Owen D. Williamson MBBS
    • Ellen N Thompson MB BS, FRCPC, Pain specialist, anaesthesiology

    Drs. Furlan and Williamson's article fails to note that the current epidemic of opioid-related deaths is chiefly connected to illicit drugs imported into Canada, not to prescribed opioids. This was made clear by BC health officials at the Nov. 18, 2016, opioid summit in Ottawa, and echoed by Alberta officials (https://www.canada.ca/en/health-canada/services/substance-abuse/opioid-conference.html).

    Conflict of Inter...

    Show More

    Drs. Furlan and Williamson's article fails to note that the current epidemic of opioid-related deaths is chiefly connected to illicit drugs imported into Canada, not to prescribed opioids. This was made clear by BC health officials at the Nov. 18, 2016, opioid summit in Ottawa, and echoed by Alberta officials (https://www.canada.ca/en/health-canada/services/substance-abuse/opioid-conference.html).

    Conflict of Interest:

    None declared

    Show Less
    Competing Interests: None declared.
  • Posted on: (10 May 2017)
    Page navigation anchor for Re: Commentary in volume 189, issue 18 - New Canadian guidance on opioid use for chronic pain: necessary but not sufficient, Andrea D. Furlan MD PhD, Owen D. Williamson MBBS
    Re: Commentary in volume 189, issue 18 - New Canadian guidance on opioid use for chronic pain: necessary but not sufficient, Andrea D. Furlan MD PhD, Owen D. Williamson MBBS
    • Heidi M. Oetter, Registrar and CEO

    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."...

    Show More

    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

    Show Less
    Competing Interests: None declared.
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New Canadian guidance on opioid use for chronic pain: necessary but not sufficient
Andrea D. Furlan, Owen D. Williamson
CMAJ May 2017, 189 (18) E650-E651; DOI: 10.1503/cmaj.170431

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New Canadian guidance on opioid use for chronic pain: necessary but not sufficient
Andrea D. Furlan, Owen D. Williamson
CMAJ May 2017, 189 (18) E650-E651; DOI: 10.1503/cmaj.170431
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