Safe prescribing. College replies (2)

The development of this or any other professional standard is not “unprecedented.” The College has a statutory obligation to set standards for medical practice, and most elements contained in the standard on safe prescribing have appeared in successive versions developed by the College’s Prescription Review Program entitled Prescribing Principles. The College has been using the prescribing principles in its work with registrants for more than 3 years. Hundreds of BC physicians have successfully operationalized them in their practices—by that measure, they are extensively field tested in real-life clinical settings.

With respect to strong opioids for chronic noncancer pain, successive, authoritative systematic reviews by Furlan,[1] Ballantyne,[2] Chou,[3] and colleagues suggest that, on average, there is weak evidence of modest relief of pain for a period of weeks or a few months, with minimal functional improvement, not superior to naproxen or nortriptyline. Dr Chou’s recent paper in the Annals of Internal Medicine documents accumulating epidemiological evidence of harms, including addiction and death. This is not to say that some patients do not benefit from long-term opioid therapy, only that the benefit is very modest, the risks significant, and the evidence tentative, despite over 20 years of escalating prescribing.

While the College participates in a consultative process during the development of professional standards, it cannot and must not abrogate its legal obligation to regulate medical practice, including prescribing. Regulation is foundational, and the advice in the standard is deliberately formulated in general terms, allowing flexibility for bedside clinical judgment. Nothing in the standard prohibits or even materially interferes with the ability of pain specialists or other physicians to safely and effectively care for their patients.

The College shares concerns that services for patients who suffer from chronic pain are often difficult to access or navigate. Solutions to that are beyond the mandate of the regulator. What is within the College’s mandate is the ability to investigate any report of physicians misapplying the standard to the detriment of patients.
—Gerrard A. Vaughan, MD
President, College of Physicians and Surgeons of British Columbia
—Heidi M. Oetter, MD
Registrar and CEO, College of Physicians and Surgeons of British Columbia


1.    Furlan AD, Sandoval JA, Mailis-Gagnon A, Tunks E. Opioids for chronic noncancer pain: A meta-analysis of effectiveness and side effects. CMAJ 2006;174:1589-1594.

2.    Ballantyne JC, Shin NS. Efficacy of opioids for chronic pain: A review of the evidence. Clin J Pain 2008;24:469-478.

3.    Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: A systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med 2015;162:276-286.

Gerrard A. Vaughan, MD, Heidi M. Oetter, MD. Safe prescribing. College replies (2). BCMJ, Vol. 58, No. 7, September, 2016, Page(s) 362 - Letters.

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