Re: Best practices in treating chronic noncancer pain

Issue: BCMJ, vol. 60, No. 7, September 2018, Pages 344-345 Letters
By: Romayne Gallagher, MD, CCFP(PC), FCFP

I was disheartened to see that Dr Peter Rothfels, in his article “Best practices in treating noncancer pain”[1] chose to use United States data and an Ontario study about emergency physician prescribing to back up his claim that, “since the mid-1990s, physicians have been increasingly prescribing higher doses and stronger opioids for their patients, particularly those with chronic noncancer pain.” Being the chief medical officer for WorkSafeBC, I would presume this article is addressed to BC physicians and their prescribing.

Prescribing of opioids varies dramatically across Canada.[2] BC’s mortality rate of 3.9 pharmaceutical opioid-associated deaths per 100 000 population has remained stable from 2004 to 2013.[3] This rate includes all pharmaceutical opioid deaths (including methadone for maintenance), intentional and unintentional, prescribed, and diverted. This pattern is strikingly different from the pattern in Ontario and the United States. The BC coroner, in reviewing prescription opioid deaths in BC from 2009 to 2013,[4] found that methadone, used as opioid agonist therapy, accounted for 30% of the deaths, and that 25% of the deaths involved codeine. In 97% of these deaths, multiple other prescribed and nonprescribed substances were involved.

Any death that implicates a prescribed drug should be investigated in order to prevent further harm, and physicians should be made aware of the outcomes of these investigations.

The narrative that implies that BC physicians have been prescribing more opioids and in greater doses leading to increased harm is not accurate.
—Romayne Gallagher, MD, CCFP(PC), FCFP
Vancouver

This letter was submitted in response to “Best practices in treating chronic noncancer pain.”

WorkSafeBC declined to respond. —Ed

References

1.    Rothfels P. Best practices in treating chronic noncancer pain. BCMJ 2018;60:244,269.

2.    Canadian Institute for Health Information. Amount of opioids prescribed dropping in Canada; prescriptions on the rise. Accessed 19 July 2018. www.cihi.ca/en/amount-of-opioids-prescribed-dropping-in-canada-prescriptions-on-the-rise.

3.    Gladstone E, Smolina K, Morgan SG. Trends and sex differences in prescription opioid deaths in British Columbia, Canada. Inj Prev 2016;22:288-290.

4.    BC Coroner’s Service & BC Ministry of Health. Preventing pharmaceutical opioid-associated mortality in British Columbia: A review of prescribed opioid overdose deaths, 2009-2013. Accessed 19 July 2018. https://www2.gov.bc.ca/assets/gov/public-safety-and-emergency-services/death-investigation/statistical/pharmaceutical-opioid-mortality.pdf

Romayne Gallagher, MD, CCFP(PC), FCFP. Re: Best practices in treating chronic noncancer pain. BCMJ, Vol. 60, No. 7, September, 2018, Page(s) 344-345 - Letters.


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