New category of opioid-related death

Romayne Gallagher

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RE:
Rupa Patel

Published on: 25 February 2018
Purdue's influence continues
Dan W Hunt

Published on: 21 February 2018
RE: Opioid-related deaths
GORDON FERGUSON

Published on: 20 February 2018
Taking unnecessary aim at MAID
Edward S Weiss

Published on: 19 February 2018

Published on: (25 February 2018)

RE:
Rupa Patel, Family Physician, Kingston Community Health Center, Assistant Professor Queens University Department of Family Medicine
Upon reading this article, I was reminded of former NEJM editor, Dr. Marcia Angell, and her article titled: "Is Academic Medicine for Sale?". Written in 2000, she explains the need for those writing a commentary or editorial to have a strict standard for freedom from bias. As editorialists do not provide data, but instead selectively review the literature and offer their judgments, it is important they have no important financial ties to companies that make products related to the issues they discuss. (1)

In this article, the author compares the experience of people living with chronic pain with those who are facing imminent death. This comparison is inaccurate and diminishes the experience of terminal illness. However, my main issue of concern is that an author with obvious conflicts of interest was allowed to publish an opinion piece.

The factors that created the opioid crisis have shown us that the influence of industry in academia is not a relationship that is unbiased or mutually beneficial. I would have expected that the editors of a national journal of Family Medicine would understand this. I suggest the editors at CFP take a look at Dr. Angell's prescient article and adopt the higher standards needed to maintain integrity in academic journals.

Reference: 1. Angell M. Is academic medicine for sale? [editorial] N Engl J Med 2000;342: 1516-1518.

Competing Interests: None declared.
Published on: (21 February 2018)

Purdue's influence continues
Dan W Hunt, Rural Family Doctor, Lecturer in the Department of Family Medicine at the University of Manitoba
I'm disappointed that CFP continues to publish pro-opioid articles by authors who have declared conflicts of interest with opioid manufacturers. I think it's telling that the only authors for the YES side of the debate around the new opioid guidelines both have conflicts of interest with opioid manufacturers.

Competing Interests: None declared.
Published on: (20 February 2018)

RE: Opioid-related deaths
GORDON FERGUSON, family doctor, West Nipissing Community Health Centre
I am disturbed that the CFP has published this article. I do not know Dr Gallagher, but an article touting the benefits of treating non-cancer pain with opioids - in the elderly - by someone who has received honoraria from Purdue Pharma, a big seller of opioids, strikes me as not too far from the key opinion leader articles which encouraged the opioid crisis in the first place. At the very least we should be aware of the size of the honoraria before deciding on the value of the piece.

Competing Interests: None declared.
Published on: (19 February 2018)

Taking unnecessary aim at MAID
Edward S Weiss, Family Physician and MAID Provider, n/a
I appreciate Dr. Gallagher's concern for the inadequate treatment of pain in our elderly patients, and I concur that the judicious use of opioid therapy can make a world of difference to patients suffering from chronic degenerative diseases, such as osteoarthritis and spinal stenosis. However, I take issue with her insinuation that medical assistance in dying (MAID) will become a de facto alternative to proper pain management.

Multiple studies have shown that the majority of patients who seek MAID do so not because of unrelieved symptoms, such as chronic pain, but because of more existential suffering, such as loss of autonomy and an inability to enjoy life. (1,2) This is borne out by my clinical experience as a MAID provider, and many of my colleagues anecdotally report this as well. A great majority of the patients I assess have already been receiving exemplary palliative care and symptom management, and in those few situations where unrelieved pain is the primary driver of a patient's MAID request, it is most often the case that they have already tried multiple therapeutic strategies, including various opioid analgesics, to help ameliorate their suffering, without significant success.

Untreated and undertreated pain in the elderly is a real and worrisome phenomenon, but it should not be conflated with unfounded fears and prejudices about MAID.

References:

1. Hedberg K and New C. Oregon's Death With Dignity Act: 20 Years of...
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I appreciate Dr. Gallagher's concern for the inadequate treatment of pain in our elderly patients, and I concur that the judicious use of opioid therapy can make a world of difference to patients suffering from chronic degenerative diseases, such as osteoarthritis and spinal stenosis. However, I take issue with her insinuation that medical assistance in dying (MAID) will become a de facto alternative to proper pain management.

Multiple studies have shown that the majority of patients who seek MAID do so not because of unrelieved symptoms, such as chronic pain, but because of more existential suffering, such as loss of autonomy and an inability to enjoy life. (1,2) This is borne out by my clinical experience as a MAID provider, and many of my colleagues anecdotally report this as well. A great majority of the patients I assess have already been receiving exemplary palliative care and symptom management, and in those few situations where unrelieved pain is the primary driver of a patient's MAID request, it is most often the case that they have already tried multiple therapeutic strategies, including various opioid analgesics, to help ameliorate their suffering, without significant success.

Untreated and undertreated pain in the elderly is a real and worrisome phenomenon, but it should not be conflated with unfounded fears and prejudices about MAID.

References:

1. Hedberg K and New C. Oregon's Death With Dignity Act: 20 Years of Experience to Inform
the Debate. Ann Intern Med. 2017;167:579-583.

2. Li M et al. Medical Assistance in Dying — Implementing a Hospital-Based Program in Canada. N Engl J Med. 2017 May 25;376(21):2082-2088.
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Competing Interests: I am on the Physicians' Advisory Committee of Dying with Dignity Canada, and am a member of the Canadian Association for MAID Assessors and Providers. I have no financial conflicts of interest.