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

Drs Gallagher and Hatcher dismiss thousands of preventable Canadian deaths each year as “illicit opioid–related deaths.”^1,2 This denigrates the victims of the opioid crisis and misdirects the blame. People die after using opioids as prescribed by their doctors. There is no viable explanation for the massive increase in opioid-related deaths since the 1990s other than the sustained increase in opioid prescribing.^3,4 Spreading false information about opioids—such as claiming that doctors could “weed out addicts” with newer opioid products—was the admittedly illicit activity that caused these deaths.^5–9

Purdue Pharma paid Dr Brian Goldman to spread information about opioids before he decided to stop and warn others about the inescapability of “corporate bias.”^10,11 The scattershot piece from Drs Gallagher and Hatcher encourages prescribing high-strength products such as 80-mg oxycodone and 30-mg hydromorphone capsules, which are sold by the company that pays them.

Drs Hatcher and Gallagher incorrectly claim that the guideline recommendations about opioid dosing below 50 and 90 morphine milligram equivalents per day were “based on a poster presentation (not a published paper).”¹ The guideline cites more than 20 published studies in support of these recommendations.^12–34 The US Centers for Disease Control and Prevention makes the same dosing recommendations.^35–37 The available benefit and risk data do not support prescribing products that provide 240 or 300 morphine milligram equivalents per day, such as the ones sold by Purdue Pharma.

Drs Gallagher and Hatcher also fail to acknowledge that reducing prescribing as recommended in the guideline can save lives and reduce suffering. They envision no benefits from the guideline but imaginations run wild when dreaming up harms such as “more than half our population”¹ being denied opioids and people receiving euthanasia because of the guideline recommendations.¹

Rather than concocting outlandish misapplications of the guideline by clinicians and regulators, my colleagues should have considered why society wants to curb inappropriate opioid prescribing. The federal opioid strategy predated the guideline: “The growing number of overdoses and deaths caused by opioids ... is a national public health crisis.”³⁸

When the opioid crisis is over, we will wonder why it took so long to reduce opioid prescribing. For now, 2 doctors who received funding from a company that misled doctors about opioids can prominently disparage a guideline that recommends only modest prescribing reductions for chronic noncancer pain.