Complexity of the opioid problem

I thank Drs Ferguson¹ and Weiss² for their letters in response to my article “A new category of opioid-related death,”³ which was published in the February issue of Canadian Family Physician.

Dr Ferguson writes that the article is “touting the benefits of treating noncancer pain with opioids in the elderly by someone who has received honoraria from Purdue Pharma”¹ and claims it is akin to literature that he claims got the opioid crisis going. His black-and-white view of this complex situation is one of the reasons I wrote the article. I was concerned about my clinical experiences in treating pain in older adults. For a variety of reasons (fear of scrutiny of prescribing, fear of harming the patient, lack of interest) many physicians are not educating themselves about the complexity of this problem and responding appropriately, but are merely deciding that opioids are not to be used in chronic noncancer pain. Even the national opioid guideline⁴ clearly states that its guideline includes the safe use of opioids in non-cancer pain. Furthermore, the guideline recognizes that if pain persists and is moderate to severe, a trial of opioids should be undertaken.

Dr Weiss, who also has a conflict of interest in being an advisor to Dying with Dignity Canada, accuses me of conflating lack of treatment of pain with “unfounded fears and prejudices about MAID [medical assistance in dying].”² I do not think fears are unfounded, as I have already seen cases of poor symptom management lead to decline in overall health and eventually to a request for MAID.

Pain BC, an organization of pain patients, pain practitioners, and volunteers that advocates and educates about chronic pain, held a webinar for health care professionals around the eligibility criteria for MAID because of patients’ and health care professionals’ questions about MAID for patients with chronic pain. I agree with Dr Weiss that many patients who access MAID do receive palliative care before it, but palliative care in Canada is a patchwork of services and many still do not get access to high-quality palliative care.⁵

I urge all physicians to take the time to understand this complex situation not as an “opioid crisis” but as a “poisoning crisis” (illicit fentanyl) in a society that does not do enough to prevent and treat the compulsion to abuse substances, relying on mitigation of harm by reducing access to the substance. The pendulum of support for the use of opioids in pain has swung back and forth now for at least a century with collateral damage each time. Good books on the history of opioid regulation are The American Disease by David Musto⁶ and Pain: A Political History by Keith Wailoo,⁷ both of which I recommend to Drs Ferguson and Weiss, as well as to all other physicians.

As for Dr Ferguson’s criticism of my potential conflict of interest,¹ my yearly honoraria for talks about pain management for Purdue Pharma are less than 4% of my income from caring for patients.

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