Dialogue Volume 13 Issue 2 2017 - Page 8

Letters to the Editor than from hyperglycemia. In a 2014 paper 2 , the authors found that hospital admission rates for hypoglycemia now exceed those for hyperglycemia among older adults. Although admissions for all adults for hypoglycemia have declined modestly since 2007, rates among those older than 75 years remain high. The authors note, “Hospital admissions for severe hypoglycemia seem to pose a greater health threat than those for hyperglycemia.” Sincerely, The Geriatrics and Long-Term Care Death Review Committee Office of the Chief Coroner for Ontario Dear Editor Re: Safe Opioid Prescribing for Community Physicians (Dialogue, Volume 12, Issue 4, 2016) Dialogue (Issue 4, 2016) republished the Institute for Safe Medication Practices’ key messages about safe opioid prescribing for community physicians. They echo those of the 2010 Canadian Guideline for Chronic Non-Cancer that codeine and tramadol are weak opioids that constitute the reasonable and safest starting points in opioid pain management with lower risks of abuse and addiction. The 2017 Canadian Guideline revision makes no qualitative statement in regard to different opioids. These directives rather skirt the truth in terms of both safety and efficacy conferring the illusion of utility cloaked with an undue sense of security. Codeine, as we all know, is not even an opioid but a highly problematic pro-opioid whose analgesic effects are almost entirely attributed to its principal metabolite, morphine. A CMAJ editorial – “Has the time come to phase out codeine?” – suggested that the unpredictable pharmacokinetics of codeine presented a danger within our increasingly multiethnic society. Amongst the opioid deaths in Ontario between 1991-2004, codeine was the sole opioid used in 20%. (CMAJ 182(17):1825 November 23, 2010). Tramadol has its own issues. Its abuse potential is becoming known worldwide. Its inherent “dual-action benefit” in terms of increased availability of noradrenalin and serotonin in addition to diminishing pain perception makes its theoretical attractiveness as a substance of abuse and addiction undeniable. Indeed, abuse statistics show a rising trend with tramadol. Furthermore, yearly tramadol-associated deaths had doubled to 154 in the UK between 2008 and 2011; more than tripled to 379 from 2003 to 2011 in Florida. Meanwhile, scripting of this “safe” opioid in the U.S. had gone from 25,000,000 to 40,000,00 scripts from 2008 to 2012. All opioids are two-edged swords. Yet we are all trying to prescribe in a “compassionate” manner to alleviate apparent suffering. Consequently, instead of giving in completely to patient demands for opioids or sending a patient away empty-handed, we continue to cop out and issue a script for some Tylenol No. 2, 3 or 4 or hand out some tramadol-containing samples. The messaging inherent in this practice is that we do not have the strength of our own evidence-based convictions. Admittedly there remain vast gray areas in the management of pain, compounded by deficient access to non-pharmaceutical modalities and further obscured by a profession so highly polarized into opiophobic and opiophilic prescribers. Nevertheless, the “compromise” prescription of less effectual, yet still problematic quasiopioids has little merit. Jamie Harris, MD London, Ontario 2 Lipska KJ et al. National trends in US hospital admissions for hyperglycemia and hypoglycemia among Medicare beneficiaries, 1999 to 2011. JAMA Intern Med. 2014 Jul;174(7):1116-24. 8 Dialogue Issue 2, 2017