Dear Editor
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