Re: Evidence-based opioid sparing approaches to pain management

We would like to express our concern regarding the article “Think twice: Evidence-based opioid sparing approaches to pain management.”[1] We share the authors’ concern with the current increasing death toll from poisoning of the illicit drug supply and the desire to minimize the harms from prescribed opioids. We are fearful, however, that this article will have unintended consequences for people who should be receiving opioid-based therapy. 

Despite the abstract specifying that the suggestions were not directed at cancer pain, we have learned from experience that this important distinction is often unappreciated by readers. It is important not to just briefly mention this population in passing, but to be very clear that the suggestions offered in the article do not apply to a significant number of people. The figure in the article is titled only “acute and chronic pain” and doesn’t specify what group it is intended for. The title also is not specific. The authors and the British Columbia Medical Journal are only a few of many who have allowed this oversight, but it needs to stop.

We and many colleagues in palliative care and oncology are seeing more and more patients with cancer pain who are being stigmatized in their search for a primary care provider and being refused opioid prescriptions by their established family doctor. Pain is prevalent in 30% to 50% of people who receive cancer-directed treatments and over 70% of people with advanced cancer.[2] Opioids remain the treatment of choice for moderate to severe cancer pain.[3] It was reported that the morphine equivalent daily dose (MEDD) prescribed by oncologists before referral to palliative care decreased between 2010 and 2015 to 40 mg from 78 mg at the MD Anderson Cancer Center in Texas.[4] We feel the same is happening here in BC. 

The Canadian Institute for Health Information was pleased to announce in 2019 that there had been a steady decline in the proportion of people over 65 who were started on opioids from 2013 to 2018, as well as in the proportion on long-term opioid therapy.[5] Considering the growing numbers in this age group due to our aging population, the drop in opioid prescribing in older adults is concerning. Chronic, disabling pain is more common in older adults and increasing comorbidities increases the prevalence of pain. The American Geriatrics Society, in its publication 2020 Geriatrics at Your Fingertips, still recommends opioids for persistent “moderate to severe pain (6–10), and pain not alleviated by non-opioid therapies that is severe enough to impact function and quality of life.”[6] Frail seniors, particularly those in long-term care, are not a demographic that has experienced serious harms from poisoning of the illicit supply, yet they also have had significant reductions in access to opioid-based analgesia.

We believe that messaging about opioids needs to be balanced and urge colleagues who see only the dark side of opioids to more clearly define situations to which the available evidence applies. Regarding publication style, headings are important, as sometimes they are the only parts of an article that are read. Images (such as the figure in the article) should not sacrifice subtlety in favor of simplification. 

The two sides of opioids—reliever of pain and dyspnea and demon of addiction—will never be eliminated, but opioids would be used less with access to evidence-based nonpharmacological treatments that are funded as adequately as medications so that physicians have more to offer their pain patients, no matter what kind of pain they have. One hopes that any future provincial or national pain strategy mandates the funding for these therapies.
—Romayne Gallagher, MD, CCFP(PC), FCFP
—Philippa Hawley, BMed, FRCPC

This letter was submitted in response to “Think twice: Evidence-based opioid sparing approaches to pain management.”

References

1.    Klimas J, McCracken R, Bassett K, Wood E. Think twice: Evidence-based opioid sparing approaches to pain management. BCMJ 2020;62:234-237.

2.    van den Beuken-van Everdingen MH, de Rijke JM, Kessels AG, et al. Prevalence of pain in patients with cancer: A systematic review of the past 40 years. Ann Oncol 2007;18:1437-1449.

3.    Wiffen PJ, Wee B, Derry S, et al. Opioids for cancer pain – an overview of Cochrane reviews. Cochrane Database Syst Rev 2017;7:CD012592.

4.    Haider A, Zhukovsky DS, Meng YC, et al. Opioid prescription trends among patients with cancer referred to outpatient palliative care over a 6-year period. J Oncol Pract 2017;13:e972-e981.

5.    Canadian Institute for Health Information. Opioid prescribing in Canada: How are practices changing? Ottawa, ON: CIHI; 2019. Accessed 5 October 2020. www.cihi.ca/sites/default/files/document/opioid-prescribing-canada-trends-en-web.pdf.

6.    American Geriatrics Society. Geriatrics at your fingertips: Pain. Accessed 17 September 2020. https://geriatricscareonline.org/FullText/B052/B052_VOL001_PART001_CH024?parent_product_id=B052_VOL001_PART001.