Role of regulators in safe prescribing of opioids

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 noncancer pain, and that over-regulating prescribers so they cannot undertake trials of safe and effective therapies would be unhelpful.”1

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

In our experience, patients often overvalue opioids, benzodiazepines, anticonvulsants and other drugs 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 noncancer pain is among the most challenging aspects of medical practice for patients and physicians alike. Most 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 guideline2 was started and funded by medical regulators. Since that time, the College of Physicians and Surgeons of British Columbia 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.3

Chronic pain and addiction are both medical conditions. The Canadian Medical Association Code of Ethics prohibits discrimination on the basis of medical condition,4 and regulators are very firm about asserting this obligation in communication with physicians.

The college 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 have 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 this and 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 “Guideline for Opioid Therapy and Chronic Noncancer Pain,”5 which affirms and complements other policies and will assist us in our work with physicians (although we are disappointed that the guideline fails to highlight the serious and 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.