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LetterLetters

We can’t feel their pain, but we can understand their fears

David L. Shulman
Canadian Family Physician May 2011; 57 (5) 536-537;
David L. Shulman
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The editorial by Jessica Fulton1 is admirable. She is an author who, in a scientific journal, looks at the issue of opioids for chronic, non-malignant pain from the point of view of the patient. It is refreshing to read of her ability to anticipate her patients’ fears in meeting a new physician who might have strong personal beliefs against a therapy upon which the patient depends. Patients are well aware of the terrible consequences of being cut off from their medications by an ill-informed physician, one who might also add a stern lecture based on personal philosophy rather than evidence.

Those who suffer from chronic noncancer pain have a poor quality of life, sometimes described as the lowest quality of life of any chronic noncancer disease. They have an increased risk of suicide and all-cause mortality.2–6 However, when it comes to therapy, they often see the medical establishment as obstructive and antagonistic. It is disheartening to read that those of us who do try to mitigate our patients’ suffering are singled out as being in the highest quintile of family physicians and that our prescribing habits are somehow linked to mortality from opioids.7 It seems apparent to me that the physicians who do prescribe opioids are likely those with who have a chronic pain–focused practice and probably consult with the patients most severely affected by pain, who in turn have the highest mortality due to their respective diseases.6 None of the articles cited in Fulton’s editorial provides convincing data on causation of mortality, but rather promote the questionable assumption that the opioids themselves are responsible for the increased mortality in the most severely affected patients.8,9 A climate of fear is created and physicians might be dissuaded from making correct medical decisions when treating these unfortunate patients.

Given the above, it is all the more reassuring that Dr Fulton can “sit on the same side of the desk” as her patients to discuss their prescriptions.

Footnotes

  • Competing interests

    Dr Shulman has been on advisory boards and has facilitated small group educational sessions for family physicians on behalf of the following organizations: PARC (a chronic pain patient advocacy group), the Canadian Consortium for the Investigation of Cannabinoids, Purdue Pharma, Eli Lilly, Solvay, Janssen-Ortho, Valeant, and Paladin.

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References

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    1. Fulton J
    . Opioids pain and personality. The story of a substitute physician. Can Fam Physician 2011;57:271, 272. (Eng),. (Fr).
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    1. Andersson HI
    . The course of non-malignant chronic pain: a 12-year follow-up. Eur J Pain 2004;8(1):47-53.
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    . Widespread body pain and mortality: prospective population-based study. BMJ 2001;323(7314):662-5.
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    . Pain and subsequent mortality and cancer among women in the Royal College of General Practitioners Oral Contraception Study. Br J Gen Pract 2003;53(486):45-6.
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    . Association of widespread body pain with an increased risk of cancer and reduced cancer survival: a prospective, population-based study. Arthritis Rheum 2003;48(6):1686-92.
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    1. McBeth J,
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    7. et al
    . Musculoskeletal pain is associated with a long-term increased risk of cancer and cardiovascular-related mortality. Rheumatology (Oxford) 2009;48(1):74-7.
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  4. ↵
    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
  5. ↵
    1. Dhalla IA,
    2. Mamdani MM,
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    6. Juurlink DN
    . Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone. CMAJ 2009;181(12):891-6. Epub 2009 Dec 7.
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    1. Jovey RD
    . Response to paper by Dhalla et al [Rapid Response]. CMAJ. 2009 Dec 22. Available from: www.cmaj.ca/cgi/eletters/181/12/891#256916. Accessed 2011 Apr 7.
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Canadian Family Physician: 57 (5)
Canadian Family Physician
Vol. 57, Issue 5
1 May 2011
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We can’t feel their pain, but we can understand their fears
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