Patient safety may have been put at risk by U of T pain lectures: doctor

TORONTO – Almost 1,400 former University of Toronto medical students have been contacted by the school and told to disregard the teaching materials they were given regarding the prescription pain killer oxycodone.

The move comes after a former student discovered what he characterizes as influence by a pharmaceutical company on the content of what he was taught about the drug in a mandatory course in pain management given by the university.

In a report published online Tuesday in J. Med Ethics, Dr. Navindra Persaud describes his personal encounter with a pain management course at the University of Toronto, where he was a second year medical student in 2004.

He told Global News reporter Jennifer Tryon that one part of the week-long course was a lecture series on pain medications, which seemed appropriate to him at the time.

“Looking back at the lectures, I can see some issues with the content – both of the pain medication lectures and of the reference book that was distributed to students who attended the lectures,” said Persaud.

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The reference book was a multi-authored manual that included chapters on opiates written by Dr. Roman Jovey, a GP and Medical Director for the Centres of Pain Management who served as the lecturer.

Since graduating in 2010 and becoming a doctor himself, Persaud said he noticed graphics in the book that downplayed the strength of oxycodone.

“It struck me as odd that oxycodone was being represented as a weak opioid with codeine, when in fact, it’s about one and a half times more potent than morphine, which was identified only as a strong opioid, quite appropriately,” he said.

Persaud also noticed that the reference book that seemed to put a positive spin on the drug was funded by Purdue Pharmaceuticals –the makers of OxyContin, the popular, time-released formula of oxycodone. He also learned that Jovey had worked as a consultant for the pharmaceutical company (along with many other companies, Jovey noted).

But Jovey believes any notions that Purdue Pharmaceuticals influenced the information he wrote on opiates are completely false.

“I had total control over what the content was,” Jovey told Tryon. “That book was written based on how I practiced, and it was based on the best knowledge that we had available at the time.”

Jovey added that he provided lectures and taught the University of Toronto students for free.

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He said that one controversial section of the reference book was a paragraph that said taking a medication that’s released slowly (like oxycodone) has less addictive potential than taking a short-acting drug. He acknowledges that if the drug is abused—crushed, snorted or injected—then the slow release property is eliminated.

“And who would have thought that when it came out in 1996 that people would be crushing and snorting and injecting medications? I certainly didn’t,” he said.

But Persaud says that’s not the point.

“Whether or not anything was done purposefully, I don’t think is the important issue,” he said. “The important issue is patient safety may have been put at risk by some of the information that was provided in the lectures and in the reference book.”

Persaud also points to other problems with Purdue Pharmaceuticals marketing campaigns south of the border.

“We know that long-acting opioids like OxyContin were illegally promoted in the United States,” he said. “In 2007, there was a guilty plea and a penalty of $630 million…So it’s an open question about what happened here in Canada.”

Persaud is referring to the 2007 case where Purdue Pharma pleaded guilty to misleading marketing, leading the public to believe OxyContin was less addictive than it is. It was one of the biggest drug settlements in U.S. history.

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When it comes to Purdue’s marketing of the drug, Jovey allows it may have played a part in how OxyContin became widely prescribed for non-cancer pain in Canada.

“It’s a combination of things: physicians desperately looking for something to offer patients, maybe marketing played a role, education about pain management, the idea among the pain community that this is okay to do,” he said.

Jovey believes that OxyContin is appropriate if monitored closely, and that knowing your patients and watching for flags of possible abuse or addiction are key to treating chronic pain. He still calls the text he authored for medical students “a very good book,” though he doesn’t use it anymore.

“As a result of this being brought to our attention the book was removed immediately from the curriculum, the lecturer was not invited back, our associate dean of equity and professionalism had already begun working on a number of conflict of interest disclosure guidelines for teachers—and these have been fully developed,” said Dr. Jay Rosenfield, Vice Dean of undergraduate medical professions education at the University of Toronto.

“If a medical student later acted on some of the information that was in the reference book or in the lectures, patients could have been put at risk,” said Persaud.

But Jovey believes pain management needs to be made a top priority for national strategies, and more funding is needed for something that he says costs the Canadian economy about $52 billion, on par with cancer costs.

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“If you don’t want pharma companies influencing future physicians, then someone has to pay for that education. And it has to start right from the top and go right down to medical schools,” said Jovey.

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