U of T revising pain course over pharma influence concerns
TORONTO — A complaint about perceived drug industry involvement in a pain management course for medical students has prompted the University of Toronto to revamp its curriculum.
An informal inquiry into the complaint about potential conflict of interest, lodged earlier this year by an unidentified student and two doctors in the faculty of medicine, has set out clear guidelines about how the course should be taught, by whom and with what sources of funding.
The complaint centred around students being provided a book on managing chronic pain that was funded and copyrighted by the maker of the prescription pain killer OxyContin. The book had been brought in by a non-faculty lecturer with financial ties to the drug company.
In a report obtained by The Canadian Press, inquiry head Lorraine Ferris says “time is of the essence” in revising the interfaculty pain curriculum, a 20-hour course jointly taught to medical, dental, pharmacy and nursing students.
Ferris, associate vice-provost in the department of Health Sciences Policy and Strategy, said by email that she found no evidence of wrongdoing or actual conflict of interest. “However, I was troubled by the perception of conflict of interest and therefore my recommendations … addressed this issue.”
She said planning for the revised curriculum needs to begin quickly, in time for delivery of the next course this spring.
“To revise the interfaculty pain curriculum, the sessions on pharmacotherapy of pain must include delivery of balanced information by experts in several fields, including pharmacology and opioid addiction,” she writes in her report.
“As part of their discussions, faculty will need to address important, topical and often sensitive issues regarding opioids, including, for example, opioid addiction, improper opioid prescribing, at-risk communities, illicit sales and drug diversion, ‘double-doctoring’ and recreational sharing and use of opioids.”
Dr. Rick Glazier, whose 18-year-old son died last year of an accidental overdose of the highly addictive OxyContin, and Dr. Philip Berger are both physicians at St. Michael’s Hospital, one of the University of Toronto’s teaching hospitals. The two doctors asked for an inquiry into the pain course after being approached by the medical student.
Berger said he is pleased with Ferris’s report, which “has met our concerns head-on.”
“She’s raised very serious issues of conflict of interest and made what I think is an absolutely correct statement that not only the academic community but the public more generally would find making a copyrighted and owned drug-company textbook available to students objectionable, regardless of how its assessed quality is,” he said.
“To me, and I think quite correctly, she’s called for a higher standard in a public policy area of a very high profile and of interest to both government and the public. I think it’s fair to say that the implementation of Prof. Ferris’s recommendations will make the public safer and likely will save lives.”
In often bluntly worded statements, Ferris recommends that curriculum development and accountability for the course be transferred from the Centre for the Study of Pain to the Centre for Interprofessional Education and that only University of Toronto faculty members teach the course.
Dr. David Mock, dean of dentistry at Canada’s largest university, said the four faculties involved in the centre are in the process of implementing the recommendations.
“I think this is a good thing,” said Mock. “I’m not looking at this as a hand-slap for the centre. I think what we’ve done is move it into the more modern governance system that we are developing at the university.
“The course will still be run by the people who know the most about the topic and that’s the people from the Centre for the Study of Pain. The course hasn’t been taken away from them.”
Ferris’s report also said the curriculum should not be “directly funded (in whole or in part) by industry donors who have, or may have, or be perceived to have financial interests in the assessment or management of pain.”
From 2002 to 2006, the pain course was funded by donations, included $117,000 in unrestricted educational grants from four drug companies — Merck-Frosst, Purdue Pharma, Pharmacia Canada and Pfizer — although they had no input into course content. Since 2007, the program has been funded solely from faculty budgets.
Mock said Purdue’s copyrighted book on pain management had been brought in by Dr. Roman Jovey, an unpaid guest lecturer and co-author of the book who left copies “for anyone to take.” Jovey, medical director for a chain of clinics called the Centres for Pain Management, is a member of Purdue’s speakers’ bureau, paid by the company to conduct workshops and lectures.
“It wasn’t distributed by the program,” Mock said of the book. “But we stopped that because, again, there’s reality and there’s appearances and it appeared as if we were pushing the books, so to speak. So we stopped doing that, we stopped before the inquiry.
Jovey confirmed he had left copies of the 371-page book, entitled “Managing Pain: The Canadian Health Care Professionals Reference,” for students.
“It was a gift from Purdue. I’m not at all embarrassed or ashamed. I think it’s a darn good book.
“If we all want to be politically correct and have the appearance of being politically correct, then I guess I get it, that nothing that has any kind of pharma logo or name or ownership should be given out to medical students,” he said Wednesday.
“But the losers are the medical students because I think it’s a high-quality book, it’s very readable and they’re deprived of it this year because of this controversy. And I guess they will be in the future.”
Jovey, director of the addiction and concurrent disorders centre at Credit Valley Hospital in Mississauga, Ont., said he stands behind the material in the book and “would debate anybody about that.”
However, Dr. Irfan Dhalla said he has concerns about the content of the book, which a medical student taking the course brought to his attention.
“There are definitely things that are not consistent with the evidence,” said Dhalla, a staff physician at St. Michael’s Hospital and a lecturer at the university. “For example, oxycodone … is listed as a moderate-potency opioid, when I think everybody agrees it’s a very strong opioid, up to twice as strong as morphine.”
While it’s appropriate to prescribe oxycodone for severe acute pain or cancer pain, Dhalla said the book suggests that physicians can prescribe the drug for chronic non-cancer pain with relative safety for the patient.
“And I think people with experience know that that is just not the case. When you prescribe to people with chronic non-cancer pain, it’s very difficult to do that safely,” he said, noting that the book pays little attention to issues of addiction and deaths from overdose.
“The book in several places makes reference to a claim that the rates of addiction if opioids are used for chronic non-cancer pain are very low. And they’re not nearly as low as is claimed in the book.”
In fact, a study by Dhalla and colleagues published last year showed prescription rates for opioids — including OxyContin, a long-acting form of oxycodone — soared in Ontario over the last two decades, as did the number of deaths linked to the narcotic.
What’s of greatest concern, of course, is how such information imparted to medical students as part of their curriculum will affect prescribing practices once they become doctors.
“Does it influence medical students? Absolutely. There’s no doubt that it does,” said Dhalla. “I think there’s definitely been a shift over the last 10 or 15 years in the way medical students have been taught about pain and opioids, and often you will find on the wards that the medical students and residents are much more liberal with opioids than the older physicians.”
The issue of the pharmaceutical industry possibly influencing medical school curriculum isn’t restricted to the University of Toronto, but has been an issue for universities across North America. An investigation published this week by ProPublica, an independent non-profit news organization, found faculty members from at least half a dozen U.S. medical schools — including Stanford — were paid speakers for drug companies, despite conflict of interest guidelines.
Leaving aside the U of T’s pain curriculum, Berger said the report raises the issue of the pharmaceutical industry potentially affecting undergraduate medical education in general.
“The danger is an obvious one. It is in the interests of the drug company to have physicians prescribing as many opioid medications to as many patients as possible. It’s the only way it makes its money.”
“So it raises a very serious question about whether industry-sponsored speakers or materials should ever be used in undergraduate medical education because the primary interest of the pharmaceutical industry who makes these drugs is to have people on the drugs — not to educate students properly.
“This would apply to any disease that requires medications.”
Deregulation for consumers
A man who suffered indigestion in the wee hours of the morning visited several drugstores, though most were closed, to buy medicine. He recalled memories of conveniently purchasing over-the-counter drugs that do not require prescription in his trips to the U.S. or Europe. He grew angry over the trouble in searching for a drugstore that was open. If the government wants to ease such inconvenience, it needs to allow the retail sale of over-the-counter drugs. Such drugs are displayed at the sales counter of a pharmacy, which give consumers easier access to medicine. In Korea, some have demanded since 1993 the legal sale of over-the-counter drugs at retail stores. The Health and Welfare Ministry also repeatedly promised to seek implementation of the system but nothing has changed.
Pharmacists’ groups, which oppose the sale of over-the-counter drugs at retail outlets, give the excuse of the possible overuse and misuse of drugs. Former Health and Welfare Minister Jeon Jae-hee took the pharmacists’ side, saying, “The public encounters little inconvenience because there are more drugstores than supermarkets in Korea.” According to a survey conducted in March by the Korea Chamber of Commerce and Industry, 70 percent of respondents said they “experienced inconvenience because of trouble finding a pharmacy open at night or on holidays.” Singled out were digestives, painkillers, cold medicine, disinfectant, tonic beverages and vitamin as items they wanted retail stores to sell. The ministry, which is supposedly in charge of public health and well-being, is effectively guarding the interest of the pharmacists’ community while disregarding public inconvenience and need. Seoul National University professor Kwon Yong-jin said, “This situation has been caused by the ministry being cajoled by the pharmacists’ community over the past 10 years since the separation of diagnosis and prescription of medicine.”
In a briefing on next year`s business plan by the ministry Wednesday, President Lee Myung-bak asked, “In countries like the U.S., people can buy drugs at supermarkets. What is the situation in Korea?” Health Minister Jin Soo-hee failed to give proper examples of foreign countries. The reality is that the U.S., Europe and Japan allow the sale of over-the-counter drugs at retail stores. The U.S. specifically defines the type and scope of medicine that consumers can purchase at retail stores, including supermarkets, convenience stores and gas stations. Japan approved the retail sale of certain drugs in 1998, and allowed the sale of about 95 percent of over-the-counter medicine at retail stores from June last year.
Public benefits oftentimes suffer a setback due to regulations that protect the interests of an industry. Measures designed to allow capital investment in and expand the scale of a sector requiring professional licensing, including optician’s stores, have hit a snag as well. The cap on daycare center fees, which was set to enable everyone to use daycare facilities, brings down the quality of such facilities and disrupts the diversification of daycare services. The government needs to drastically remedy regulations on the service industry to raise consumer convenience and benefits.