Skip to main content

Main menu

  • Home
  • Articles
    • Current
    • Published Ahead of Print
    • Archive
    • Supplemental Issues
    • Collections - French
    • Collections - English
  • Info for
    • Authors & Reviewers
    • Submit a Manuscript
    • Advertisers
    • Careers & Locums
    • Subscribers
    • Permissions
  • About CFP
    • About CFP
    • About the CFPC
    • Editorial Advisory Board
    • Terms of Use
    • Contact Us
  • Feedback
    • Feedback
    • Rapid Responses
    • Most Read
    • Most Cited
    • Email Alerts
  • Blogs
    • Latest Blogs
    • Blog Guidelines
    • Directives pour les blogues
  • Mainpro+ Credits
    • About Mainpro+
    • Member Login
    • Instructions
  • Other Publications
    • http://www.cfpc.ca/Canadianfamilyphysician/
    • https://www.cfpc.ca/Login/
    • Careers and Locums

User menu

  • My alerts

Search

  • Advanced search
The College of Family Physicians of Canada
  • Other Publications
    • http://www.cfpc.ca/Canadianfamilyphysician/
    • https://www.cfpc.ca/Login/
    • Careers and Locums
  • My alerts
The College of Family Physicians of Canada

Advanced Search

  • Home
  • Articles
    • Current
    • Published Ahead of Print
    • Archive
    • Supplemental Issues
    • Collections - French
    • Collections - English
  • Info for
    • Authors & Reviewers
    • Submit a Manuscript
    • Advertisers
    • Careers & Locums
    • Subscribers
    • Permissions
  • About CFP
    • About CFP
    • About the CFPC
    • Editorial Advisory Board
    • Terms of Use
    • Contact Us
  • Feedback
    • Feedback
    • Rapid Responses
    • Most Read
    • Most Cited
    • Email Alerts
  • Blogs
    • Latest Blogs
    • Blog Guidelines
    • Directives pour les blogues
  • Mainpro+ Credits
    • About Mainpro+
    • Member Login
    • Instructions
  • RSS feeds
  • Follow cfp Template on Twitter
  • LinkedIn
  • Instagram
LetterLetters

Mind the gap

Ruth Dubin
Canadian Family Physician May 2011; 57 (5) 530-531;
Ruth Dubin
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • eLetters
  • Info & Metrics
  • PDF
Loading

Do not put your faith in what statistics say until you have carefully considered what they do not say.

William W. Watt

The article by Dhalla et al on opioid prescribing and opioid-related mortality1 reminds me of the phrase used by train and bus conductors as we step off their vehicles. They say it to ensure our safety and our safe progress as we embark on our journeys. We need to “mind the gap” between what the authors’ population-based number-crunching actually tells us and what they conclude. In focusing solely on opiate prescriptions, these authors oversimplify the many “gaps” in care that might have led to so many tragic deaths.

First we must note the gap between the massive numbers of chronic pain sufferers (1 in 5 Canadians) and the pain education received by medical students (only 16 hours compared with 87 hours for veterinarians). Family physicians, who care for most of the patients with chronic pain, receive only 3.44 hours of chronic pain management training during their residencies. And there are no licensure requirements for Canadian physicians in pain management.2–5

Our health ministry covers the cost of drugs, excluding less abuse-prone formulations (eg, tramadol, transdermal buprenorphine). Ideal chronic pain management includes biopsychosocial and rehabilitative treatment along with patient education and self-management, and exists in only a few publicly funded pain clinics, most of which have 3- to 5-year wait times.6 The gulf between recommended and received pain care is especially great for the most financially threatened members of our society—those included in this study.

Then there is the gap between what we are told about the 408 people who died in 2006 and the fact that they were each provided with “at least 1 publicly funded opioid prescription in the year before death.”1 What other drugs and substances were in their bodies when they died? (Most opioid-related deaths are linked to multiple substances, including recreational drugs, alcohol, and benzodiazepines or other sedatives.7) Did these patients suffer from chronic pain, addiction, mood disorders, or other medical conditions that predisposed them to overdose?

An unbridgeable chasm exists between the data presented and the authors’ conclusion that “family physicians might be able to reduce the risk of opioid-related harm by writing fewer opioid prescriptions.” Statistics 101 teaches that correlation does not mean causation. Yet the implication is clear: if I wrote an opiate prescription 364 days before my patient died, I am responsible.

This leap of logic seems especially naïve considering that there is no mention of universal precautions in opiate prescribing, wherein patients are screened for addiction and risk of inappropriate medication use before opioid treatment is initiated.8 This concept has been widely adopted as an educational requirement for practising physicians in the United States, yet it is mostly ignored in Canada. Ordering urine drug tests might be a surrogate marker for those physicians attempting to screen for opioid misuse. Such data would have provided useful information on how many family physicians in Ontario are aware of universal precautions.

Using a gratuitous comparison between falling HIV-related deaths and rising opiate-related deaths is ironic, considering that the increased chances of HIV survival came about after very vocal political action by the gay community. This led to massive research and development and markedly improved medical treatments, all of which turned a death sentence into a manageable disease. One can only hope that chronic pain sufferers, along with those of us who dream of restoring functional and satisfying lives, will eventually achieve the same.

Footnotes

  • Competing interests

    Purdue Pharma, Pfizer, and Paladin have provided grants or support of ongoing chronic pain educational initiatives that Dr Dubin is involved with. Dr Dubin has also received advisory board and consultant fees from Boehringer Ingelheim, Purdue Pharma, Eli Lilly, and Pfizer.

  • Copyright© the College of Family Physicians of Canada

References

  1. ↵
    1. Dhalla IA,
    2. Mamdani MM,
    3. Gomes T,
    4. Juurlink DN
    . Clustering of opioid prescribing and opioid-related mortality among family physicians in Ontario. Can Fam Physician. Vol. 57. 2011. p. e92-6. Available from: www.cfp.ca/content/57/3/e92.full.pdf+html. Accessed 2011 Apr 1.
    OpenUrlAbstract/FREE Full Text
  2. ↵
    1. Jovey R
    . Canadian pain survey 2007–2008. Toronto, ON: Nanos Research Group; 2009.
    1. Watt-Watson J,
    2. McGillion M,
    3. Hunter J,
    4. Choinière M,
    5. Clark AJ,
    6. Dewar A,
    7. et al
    . A survey of prelicensure pain curricula in health science faculties in Canadian universities. Pain Res Manag 2009;14(6):439-44.
    OpenUrlPubMed
    1. Watt-Watson J
    . Moving the pain education agenda forward: innovative models; Proceedings of the Official Satellite Symposium of the 13th World Congress on Pain; 2010 Aug 26–27; Toronto, ON.
  3. ↵
    1. Dubin R
    . Cross-Canada check-up 2010: a survey of family medicine residency training in chronic noncancer pain (CNCP) and addiction; Proceedings of the Canadian Pain Society Annual Conference; 2011 Apr 13–16; Niagara Falls, ON.
  4. ↵
    1. Clark AJ,
    2. Beauprie I,
    3. Clark LB,
    4. Lynch ME
    . A triage approach to managing a two year wait-list in a chronic pain program. Pain Res Manag 2005;10(3):155-7.
    OpenUrlPubMed
  5. ↵
    1. Cone EJ,
    2. Fant RV,
    3. Rohay JM,
    4. Caplan YH,
    5. Ballina M,
    6. Reder RF,
    7. et al
    . Oxycodone involvement in drug abuse deaths. II. Evidence for toxic multiple drug-drug interactions. J Anal Toxicol 2004;28(7):616-24.
    OpenUrlAbstract/FREE Full Text
  6. ↵
    1. Gourlay DL,
    2. Heit HA,
    3. Almahrezi A
    . Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med 2005;6(2):107-12.
    OpenUrlCrossRefPubMed
PreviousNext
Back to top

In this issue

Canadian Family Physician: 57 (5)
Canadian Family Physician
Vol. 57, Issue 5
1 May 2011
  • Table of Contents
  • About the Cover
  • Index by author
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on The College of Family Physicians of Canada.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Mind the gap
(Your Name) has sent you a message from The College of Family Physicians of Canada
(Your Name) thought you would like to see the The College of Family Physicians of Canada web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Mind the gap
Ruth Dubin
Canadian Family Physician May 2011, 57 (5) 530-531;

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Respond to this article
Share
Mind the gap
Ruth Dubin
Canadian Family Physician May 2011, 57 (5) 530-531;
Twitter logo Facebook logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Footnotes
    • References
  • eLetters
  • Info & Metrics
  • PDF

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • Response
  • Google Scholar

More in this TOC Section

  • Correction
  • Long-term monitoring needed for lichen sclerosus
  • Private-public partnerships not a threat to Canada’s health care system
Show more Letters

Similar Articles

Navigate

  • Home
  • Current Issue
  • Archive
  • Collections - English
  • Collections - Française

For Authors

  • Authors and Reviewers
  • Submit a Manuscript
  • Permissions
  • Terms of Use

General Information

  • About CFP
  • About the CFPC
  • Advertisers
  • Careers & Locums
  • Editorial Advisory Board
  • Subscribers

Journal Services

  • Email Alerts
  • Twitter
  • LinkedIn
  • Instagram
  • RSS Feeds

Copyright © 2025 by The College of Family Physicians of Canada

Powered by HighWire