The real crisis of chronic pain

Thank you for publishing the healthy debate¹ in the May issue of Canadian Family Physician surrounding the article by Dhalla and colleagues on prescribing of opioid analgesics by family physicians and related mortality.²

Where Dhalla et al see stridency³ we see passion, on the part of all the clinician writers,¹ to improve patient safety, function, and quality of life. We believe that an important change in how governments, health care providers, and chronic pain sufferers themselves perceive and manage chronic noncancer pain (CNCP) is necessary to improve the real crisis of poorly treated pain.

One recent positive step forward deserves mention. On April 29, 2011, the College of Family Physicians of Canada (CFPC) approved the formation of a CNCP group in the Section of Family Physicians with Special Interests or Focused Practices, which will reach out to all primary care physicians and trainees to improve competence in CNCP management. Universal precautions in opiate prescribing and the Canadian opioid guidelines will be an important part of this initiative.

From their apparent higher moral ground, Dhalla and colleagues³ trot out that old trope that we on the “pro-opiate” side of the issue are controlled by our contacts with the pharmaceutical industry. Instead of defending their science, they turn to personal attack. Further, they imply that we, rather than Health Canada, are responsible for the quality of pharmaceutical research.

In his letter, Dr Kahan states that “high prescribers … were influenced by an intense and sustained pharmaceutical marketing campaign.”⁴ This unsubstantiated statement deserves some actual research. Plato recognized that “knowledge is true opinion.” One of our first orders of business as leaders of the CFPC’s CNCP group in the Section of Family Physicians with Special Interests or Focused Practices will be to survey our College’s members on the sources of their chronic pain knowledge.

We also remind Dr Dhalla and colleagues that the Canadian Pain Society content is accredited by both the CFPC and the Royal College of Physicians and Surgeons of Canada, as are most continuing medical education events by other medical organizations, which, barring government subsidies, are also sponsored by pharmaceutical companies.

True solutions to the complex problem of harms related to opioid prescribing for pain require the availability of other biopsychosocial treatment options rather than a simplistic focus on reducing opioid prescribing by family physicians.

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