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Nav Persaud: “Doctors should not teach medical students and work for pharmaceutical companies at the same time.”

Fred Lum/The Globe and Mail

As a medical student at the University of Toronto, Nav Persaud had to take a compulsory program on pain management, organized by a university centre that made pain research its specialty.

The treatment of chronic pain has become a deeply controversial area of medical practice, where increased prescribing of opioids has been associated with a rapid increase in fatal overdoses.

But the pharmacotherapy course taken by Persaud and hundreds of other University of Toronto students up until 2010 soft-pedalled the dangers of opioids for treating chronic pain – not surprisingly, in retrospect, because the course was rife with conflicts of interest.

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As Persaud discovered, his compulsory educational program was financially supported by the pharmaceutical industry, taught by an outside lecturer from a drug-company speakers' bureau and supplemented by a free reference book paid for by Purdue Pharma, manufacturers of OxyContin.

In an article published this month in the London-based Journal of Medical Ethics, Persaud has used his experience as a warning about drug-industry influence in undergraduate medical education, where conflict-of-interest standards remain lax.

"Doctors should not teach medical students and work for pharmaceutical companies at the same time," says Persaud, now a physician and researcher at St. Michael's Hospital in Toronto. "This association can be linked with dubious information presented to students and could have a negative impact on patient care. When you go to the doctor, you want to know that you're getting the advice that's best for you and not something that's based on the marketing plan of a pharmaceutical company."

Pharmaceutical-industry involvement in university research is widespread through funding of expensive clinical trials. But these at least have to follow guidelines about openness, ethical conduct and declared conflicts of interest. Even then, says Persaud, personal relationships are developed that have the potential to be inappropriate.

Although the University of Toronto brought the lecture program in-house after 2010 and ended the distribution of the industry-supported reference book, Persaud believes the school has the obligation to inform earlier medical graduates about the questionable content in their pain-management education.

In particular, he notes that the pharmacotherapy lectures and the reference book distributed to students referred to oxycodone (the active ingredient in OxyContin) as a weak opioid, citing a "modified" World Health Organization pain-relief chart. But the original WHO chart does not mention oxycodone, which is actually more potent than morphine – labelled a strong opioid by WHO.

The adverse effects of opioids were downplayed in the lectures, Persaud notes in his JME article, and no studies related to the risks of addiction, misuse or death were cited.

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"Since patient safety is at stake and we know prescription opioid misuse is a large problem," he says, "I think the medical school should err on the side of caution and notify previous students."

In the meantime he wants to open up the conversation about the pharmaceutical industry's influence on the education of young doctors – a problem he believes could be widespread, simply because there is little oversight of potential conflicts at the undergraduate level.

"We could have policies that restrict the amount of money medical-school lecturers can receive from pharmaceutical companies. If that were made clear, doctors would have to make the choice between taking money from the companies and teaching students."

He hopes that his experience – he was the original complainant in the University of Toronto case – will encourage other students and educators to speak up against the inappropriate influence of an industry on professional education. But having faced threats of litigation in the publication of his article, Persaud acknowledges that his cause is a challenging one.

"If papers like this don't get published and people who share my concerns don't speak up, I won't be surprised if this problem continues."

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