Clustering of opioid prescribing—what is really going on?

In the recent study by Dhalla et al,¹ the statement that “the findings in this study suggest that family physicians might be able to reduce opioid related harm by writing fewer prescriptions” is unsupported by the data presented. Further, in the absence of information regarding the appropriateness of the prescriptions written, such action might harm patients.

The authors have failed to consider alternate explanations for the data. This study used data from the Ontario Public Drug Program; it is important to remember that this population has less access to determinants of health and will likely be a sicker population than the general Ontario population. In addition, those requiring opioids might have more severe illnesses. It is possible that the variation in prescribing is related to the fact that many family doctors prefer to avoid seeing patients with chronic pain. There are a number of potential reasons that might contribute to this. The cases are complex and time consuming. People with chronic pain have been found to have the worst quality of life and high levels of depression compared with patients suffering from other chronic diseases.² They have often suffered job loss or are on disability leave, so there are forms that must be completed. Many have been injured in motor vehicle accidents, so there might be lawsuits requiring the involvement of the health care professional.³ There is also inadequate training and education in medical school for chronic pain management—in fact veterinarians get 5 times more education regarding pain management than physicians do.⁴ In many cases, family physicians with an interest in pain management have had to seek specific training offered through continuing medical education programs, through the Canadian Pain Society Special Interest Group refresher courses, or through mentorship networks such as those offered by the Nova Scotia Chronic Pain Collaborative Care Network. It is possible that some of the physicians in this study have developed an interest in assisting people with pain and are prescribing appropriately according to the guidelines available.

Opioids are a key treatment for moderate to severe pain. There is little argument that they are appropriate in acute and cancer pain. There is evidence that opioids exhibit efficacy in some people with chronic pain.^5,6 This study did not collect data that allowed for an assessment of appropriateness of prescribing and therefore should not make suggestions to decrease opioid prescribing or to increase regulatory scrutiny, as this might have an adverse effect on the quality of life of many people living with pain. There is a substantial problem with access to appropriate treatment for people with pain in Canada,⁷ and there is a need for a national strategy to address the problems of undertreatment, lack of education, and inadequate funding for research.⁸

It is very important to ensure a balanced perspective in this area so that we do not cause further harm to a group of people who are already suffering.

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