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 on 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.
Prof. Ferris, associate vice-provost in the department of Health Sciences Policy and Strategy, said by e-mail 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.
"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.
"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."
Rick Glazier, whose 18-year-old son died last year of an accidental overdose of the highly addictive OxyContin, and Philip Berger are both physicians at St. Michael's Hospital, a U. of T. teaching hospital. The two asked for an inquiry into the pain course after being approached by the medical student.
Dr. Berger said he is pleased with Prof. 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.
In often bluntly worded statements, Prof. 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 U. of T. faculty members teach the course.
David Mock, dean of dentistry, said the four faculties involved in the centre are in the process of implementing the recommendations.
"I think this is a good thing," said Dr. 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."
Prof. 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.
Dr. Mock said Purdue's copyrighted book on pain management had been brought in by Roman Jovey, an unpaid guest lecturer and co-author of the book who left copies "for anyone to take." Dr. 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 was a gift from Purdue. I'm not at all embarrassed or ashamed. I think it's a darn good book," Dr. Jovey said.
"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."
Dr. 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, Irfan Dhalla said he has concerns about the book's content. "There are definitely things that are not consistent with the evidence," said Dr. 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, Dr. 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.
A study by Dr. 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 Dr. 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."