National opioid crisis
======================

* Abhimanyu Sud

Friesen and colleagues1 have provided invaluable insight into unsafe opioid prescribing in Canada over a time when we have seen unprecedented increases in prescriptions for opioids2 and consequently the number of associated harms, including death.3

As an opioid prescribing educator, I agree with Lucyk and Nelson’s contention in their linked commentary4 that we require improved prescriber education. However, given the breadth of the crisis, our approach to unsafe prescribing needs to be far more comprehensive, rational and coordinated.

An excellent example of the disconnectedness of our current efforts comes from British Columbia and the decision of its regulatory college to set new standards for opioid prescribing for chronic noncancer pain based on the recently released guidelines from the Centers for Disease Control and Prevention.5 These new standards include what essentially amounts to a maximum dose of 90 MEQ (milligrams of morphine equivalent). Yet, as just one example, that province’s formulary still carries transdermal fentanyl in doses more than four times this maximum in the form of 100 μg fentanyl patches (400 MEQ).

We know that decisions about what is available on formulary influences prescribing practices.2,6 With multiple inconsistent factors influencing prescriber behaviour, how can we expect a consistent response from physicians? In no other area of medicine do we see, or would we tolerate, such divergence and inconsistency of prescribing practices.7

As we continue to recognize the lack of good evidence for the use of strong opioids in chronic noncancer pain (despite what Lucyk and Nelson claim about the effectiveness of fentanyl4) and the substantial harms associated with their use, it is time that policy-makers, regulators, educators, prescribers and the public come together to form a consistent, rational and safe approach to the use of these potent medications.

## References

1.  Friesen KJ, Woelk C, Bugden S. Safety of fentanyl initiation according to past opioid exposure among patients newly prescribed fentanyl patches. CMAJ 2016;188:648–53.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxODgvOS82NDgiO3M6NDoiYXRvbSI7czoyNDoiL2NtYWovMTg4LzE1LzExMDcuMS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

2.  Gomes T, Mamdani MM, Paterson JM, et al. Trends in high-dose opioid prescribing in Canada. Can Fam Physician 2014;60:826–32.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiY2ZwIjtzOjU6InJlc2lkIjtzOjg6IjYwLzkvODI2IjtzOjQ6ImF0b20iO3M6MjQ6Ii9jbWFqLzE4OC8xNS8xMTA3LjEuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

3.  Dhalla IA, Mamdani MM, Sivilotti ML, et al. Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone. CMAJ 2009;181:891–6.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMDoiMTgxLzEyLzg5MSI7czo0OiJhdG9tIjtzOjI0OiIvY21hai8xODgvMTUvMTEwNy4xLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

4.  Lucyk S, Nelson L. Consequences of unsafe prescribing of transdermal fentanyl. CMAJ 2016;188:638–9.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxODgvOS82MzgiO3M6NDoiYXRvbSI7czoyNDoiL2NtYWovMTg4LzE1LzExMDcuMS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

5.  Professional standards and guidelines. Safe prescribing of drugs with potential for misuse/diversion. Vancouver: College of Physicians and Surgeons of British Columbia; 2016. Available: [www.cpsbc.ca/files/pdf/PSG-Safe-Prescribing.pdf](http://www.cpsbc.ca/files/pdf/PSG-Safe-Prescribing.pdf) (accessed 2016 July 7).
    
    

6.  Fischer B, Jones W, Murphy Y, et al. Recent developments in prescription opioid-related dispensing and harm indicators in Ontario, Canada. Pain Physician 2015;18:E659–62.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=26218958&link_type=MED&atom=%2Fcmaj%2F188%2F15%2F1107.1.atom) 

7.  Dhalla IA, Mamdani MM, Gomes T, et al. Clustering of opioid prescribing and opioid-related mortality among family physicians in Ontario. Can Fam Physician 2011;57:e92–6.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiY2ZwIjtzOjU6InJlc2lkIjtzOjg6IjU3LzMvZTkyIjtzOjQ6ImF0b20iO3M6MjQ6Ii9jbWFqLzE4OC8xNS8xMTA3LjEuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9)