Rebuttal: Will the new opioid guidelines harm more people than they help?

Our colleague states, “Falsehoods caused the opioid crisis and falsehoods keep it going.”¹ The falsehood he promotes is that today’s opioid crisis has a single, recent origin. Opioids have been used by humans for millennia, and attempts to mitigate harm by eliminating the drug have been ongoing since 1729, when the Emperor of China banned opium imports owing to harms.² The “war on drugs” has repeatedly failed to stem substance abuse, causing many countries to adopt harm-reduction strategies and improve recognition and treatment of substance abuse.

Reducing the compulsion to abuse substances such as tobacco, alcohol, and drugs should be our goal through fundamental changes in society to reduce poverty, adverse childhood events, and family dysfunction.³ Reduced stigma surrounding substance abuse is urgently needed so that users will not use in seclusion and die from overdose for lack of administration of naloxone.

We are surprised that our colleague fails to mention the devastating results of cheap fentanyl imported into North America and sold as heroin, ecstasy, and cocaine. From January to October 2017, fentanyl was detected in approximately 83% of illicit drug overdose deaths in British Columbia⁴—far more common than prescription-related deaths.

In quoting figures from the United States and Ontario and applying this to all regions, our colleague does not acknowledge that the prescribing of opioids varies dramatically across Canada⁵ and that different strategies might be needed depending on the region. For example, British Columbia’s mortality rate of 3.9 pharmaceutical opioid–associated deaths per 100 000 population has remained stable from 2004 to 2013.⁶ This rate includes all pharmaceutical opioid deaths (including methadone for maintenance), intentional and unintentional, prescribed and diverted. This pattern is strikingly different from Ontario.

Many pain patients have a low risk of substance abuse and take their medications as directed, but because of guidelines and other regulations, physicians will reduce or stop the opioid. Many patients’ pain will be inadequately managed, with multiple consequences including some patients seeking medication on the street.

If physicians do not take the time to understand the complexities, the politics, and the ethics of this complex problem, they might decide that it is expedient to avoid prescribing opioids at all.

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