Forcing Patients Off Opioids is Insane & Unethical

Forcing Pain Patients Off Their Meds Won’t End the Opioid Crisis – by Maia Szalavitz – Aug 2018

A relentless focus on reducing the number and dosage of opioid prescriptions is wreaking hell on people in intractable pain—while failing to treat addiction or reduce overdose deaths.

And, as a new study questions whether prescription opioid availability overall is actually declining, chronic pain patients continue to be thrown into the maw of a policy juggernaut that shows no signs of changing in response to failure.

As they say in AA, doing the same thing over and over and expecting different results is insanity, yet that’s exactly what the anti-opioid campaign is doing.  The people forcing these increasing opioid restrictions are literally insane.

In Oregon, a state Medicaid committee is now determining whether all existing chronic pain patients on opioids should be forcibly tapered starting in 2020 because of concerns about “overdose and death“—and all new prescriptions be limited to 90 days, with few exceptions, mainly for people who are dying.

In Tennessee and several other states, some 50,000 pain patients may be left in opioid withdrawal as a chain of pain clinics shuts down, following the introduction of new state laws restricting prescribing and the indictment of top management for Medicaid fraud.

As Congress and state legislatures continue to debate, and states, pharmacies, and insurers enact new policies that squeeze patients even more, hospitals are experiencing actual shortages due to federal regulatory cuts in supply quotas and manufacturing issues.

Yet the New York Times reported last week that overdose deaths hit an all-time high of 72,000 in 2017. More than two-thirds of these deaths—some 49,000—included an opioid, typically a non-pharmaceutical fentanyl.

Meanwhile, a new study published in the BMJ suggests that all of this may not even be reducing the number of people exposed to opioids during medical care.

This invalidates the argument that restricting opioid doses will decrease the number of overdoses in the future.

The theory is that merely exposing people to opioids can “cause” them to become addicted. But hundreds of thousands of people are exposed to opioids every year after surgeries or painful injuries and the vast majority simply stop using them when the pain is gone.

The researchers looked at how many individuals received opioids—not just the total number of prescriptions or doses distributed

The authors found that 14 percent of commercially insured people had been prescribed an opioid within the past year. That number was 26 percent for Medicare seniors and 52 percent for those with disability, which sounds high but is less surprising given that people granted permanent disability benefits tend to be seriously ill and undergo many painful procedures.

However, rather than falling as expected throughout the time period, these percentages didn’t budge.

Essentially, while the overall amount of opioids being prescribed is indeed shrinking, the people with the most complex medical problems—often, meaning the most severe pain—who receive the highest doses, seem to be taking the biggest hit.

Meanwhile, the least-needed prescriptions—like someone prescribed 60 Vicodin following surgery who leaves 50 of them in the medicine cabinet where curious teens can later get them—may have barely been affected.

As Stefan Kertesz, professor of preventive medicine at the University of Alabama School of Medicine, put it in a Twitter thread, “The headline I would offer is 

‘Large, well-documented US opioid Rx reductions have not involved changing a long-term American habit of sloppy short-term prescriptions, but instead reflect changes in care for a small number of sick people on long-term prescriptions.’

The agony of chronic pain patients, who have begun to organize against what they experience as a war on them, bears this out. “It’s pretty horrible,” says Kate Nicholson, a civil rights attorney, pain patient, and advocate.

“I hear lots of reports of people losing the ability to work and function. They were able to be employed, and now they’re bedridden. I hear lots of problems with medical decline and an increasing number of anecdotal reports of suicide.

The data supporting the idea that most of the cuts are coming from doctors forcibly tapering or simply refusing to continue to prescribe opioids to existing chronic pain patients is now piling up. For instance, the same CDC report that found a 19 percent reduction in overall prescribing also showed a 48 percent cut in high-dose prescribing.

And the BMJ study found that 62 percent of all opioids dispensed went to the 3 percent of people who took them long-term, amongst people with private health insurance.

Among people with disabilities in Medicare Advantage, the 14 percent of people who took opioids chronically used 89 percent of the drugs in that group.

What we have here is what economics geeks will immediately recognize as a Pareto distribution—more popularly known as the 80/20 rule. It’s found in numerous populations, where a small minority accounts for the vast majority of consumption. For example, more than 80 percent of all alcohol sold is imbibed by the 20 percent of drinkers who drink heavily.

But when you’re talking about pain treatment, the biggest consumers may be exactly the people whoshould be taking these drugs.

research shows that the risk that appears to be associated with high doses is actually more strongly connected with the type of people who tend to take such doses—people with addiction and/or people with complex pain conditions and multiple psychiatric and physical problems

And there’s no data suggesting that forcing people to stop the medication improves anyone’s quality of life—while there is increasing evidence of harm.

To a government whose focus is on cutting a specific number of doses, chopping the head off a Pareto distribution is tempting: You will see rapid and large reductions by targeting the small number of consumers who use most of the product.

But if the idea is to reduce risk of new addiction, which studies suggest largely begins when young people misuse drugs that were prescribed to others or when they get large prescriptions of their own, this is exactly the opposite of what should be done.

Chronic pain patients on high doses are already exposed to opioids; it’s acute pain patients who may not have been. And contrary to popular belief, once someone is already taking opioids long term for chronic pain, their risk of addiction doesn’t continue to rise.

This is an important point for chronic pain patients: the risk of addiction is from the initial exposure and then becomes less as a person takes their pain medication over the years.

That’s because people either like the “high” or they don’t—they rarely suddenly shift from hating the numbness and nausea to finding it euphoric. They either immediately take to an opioid rapidly, they tolerate the drug because it relieves pain, or they stop.

This shows the three general responses to opioids:

  1. feel euphoric, like them too much and slide into misuse and addiction
  2. feel pain relief and continue taking them as prescribed
  3. feel awful and stop taking them

Of course, some chronic pain patients on high doses may actually be people with addiction who are selling some of their drugs to support themselves—but this is obviously not the case among the many high-dose patients with documented physical findings and years-long histories of appropriate medical use.

Outside of the few remaining pill mills that sell prescriptions for cash, it is now clearly extremely difficult to get opioid doses from the medical system that are outside the guidelines set in 2016 by the CDC. And cutting off addicted patients doesn’t cure them either, it just increases their risk of overdosing on street drugs.

in Oregon: A 14-member committee that includes a chiropractor, three acupuncturists, and just one pain patient representative (and, apparently no one specializing in addiction) is considering forcibly tapering all Medicaid patients taking opioids for chronic pain.

This is not congruent with the CDC Guidelines—which recognize that some patients in chronic pain will continue to require opioids—nor does it have any scientific basis.

It’s essentially an experiment by a state health department in one-size-fits-all medicine, carried out on the poorest and sickest patients without consent—one that really would never pass an ethics board if proposed by actual scientists.

Here, Ms. Salavitz makes an interesting and valid point: the forced tapering that’s being done in medical institutions would never be allowed as a scientific experiment because it is so clearly unethical.

Patient protests do seem to have caught the panel’s attention and slowed the momentum of the proposal—but it has not been dropped.

So long as we remain laser-focused on cutting prescription numbers rather than helping people with pain and with addiction, the toll of death, disability, and agony will continue to rise.

8 thoughts on “Forcing Patients Off Opioids is Insane & Unethical

  1. canarensis

    I’m wading thru the papers the idiots in Oregon supposedly based their extremist proposal on, to try & give a rebuttal at the next hearing. The main ‘evidence based’ source roundly supports using opioids AND trying the so-called alternative treatments. It only suggests tapering/removing patients with greater negative side-fx than positive benefits (& suggests trying different opioids before ditching them entirely). It’s bizarre; this 71 page paper that backs using pain medication and alternatives, & their take-away message was apparently “use only alternatives & ban all the effective stuff.”
    btw, it’s the Scottish National Healthcare recommendations for 2013 for chronic pain…I’d love to know how they ended up with that, since nearly all the other papers are from within Oregon. Tres bizarre!

    Liked by 1 person

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  2. KJT

    It’s, frankly, batshit insane.

    BTW, on the whole hyperalgesia hysteria: I saw a study being quoted in a paper where they found that it was a very *low* dose of morphine that caused hyperalgesia in rats, whereas a normal dose worked just fine. Which immediately made me connect the dots between that fact and my hyperalgesia (which I’ve had from birth, due to neurological hypersensitivity and EDS, and would have whether I took opioids or not) returning only when I’m forced to reduce my codeine dose, or when my liver decides not to metabolise it properly (which happens too often), or when the gap between doses has been too long. I mean, it’s… well, duh. On the basis of that, you could very well make the argument of pain patients simply being undermedicated (either by too-small doses when tolerance rises and/or too widely spaced dosage) if they develop hyperalgesia. Considering how far too many doctors think a rising tolerance is merely something that happens between the patient’s ears and not their entire body and how they only advise a further reduction or longer dosage gaps to treat it (instead of cycling opioids of trying analgesia-sparing/boosting drugs alongside the opioid), that’s more than likely. Yet one more iproblem in pain patients that could be alleviated or even prevented by more humane prescribing methods.

    Here’s the article, but I haven’t found the full text anywhere yet.

    https://www.sciencedirect.com/science/article/pii/0006899387913382?via%3Dihub

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    1. Zyp Czyk Post author

      Indeed, being humane is no longer a concern when it comes to pain. They simply don’t believe us that it’s “really that bad”.

      That study is from 1987, so it may not be online, and those few sentences don’t make much sense without further explanation. I’m not even sure clinical hyperalgesia exists. It’s too easy for a doctor to claim it when a patient’s pain is simply getting worse.

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      1. KJT

        I’ve had it used as an excuse, yeah–several doctors have gone on about opioids “being contraindicated” in hypermobility/fibromyalgia-type pain (and ignoring my endometriosis/dysmenorrhea pain with the same sweeping statement, even if it can knock me unconscious).

        The study this thing was quoted in was this one about LDN for fibro (which I’m skeptical about, as I don’t want to risk losing what little help the minimal, inadequate help my codeine still gives me). It explains what they did in the morphine study, as an example of the paradoxical reactions.

        https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3962576/

        Hyperalgesia certainly exists (I won’t bore you with my tales but they’ve involved both doctors and nurses being shocked at what happens when I have to undergo any invasive procedures), but it’s definitely criminal to use it as an excuse to deny a pain patient decent medications since that just makes it worse. My nervous system would never have got so bad pre-opiates, had I been adequately medicated for my pains in the first place. If anything, chronicised pains (endo being a good example–turning from once-a-month hell to month-round hell) are the result of opiophobia more than anything else.

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        1. Zyp Czyk Post author

          I’ve posted several articles about low-dose naltrexone for chronic pain, but i doubt it’s strong enough to help most of us. This link shows several: https://edsinfo.wordpress.com/?s=low-dose+naltrexone

          This one in particular is recent and points out te danger hidden in this type of “pain management”: https://edsinfo.wordpress.com/2018/06/24/opioid-antagonists-in-chronic-pain-management/

          I hadn’t seen the one you found – I’ll have to take a look.

          Yes, by not treating our pain until it’s etched deeply into our nervous system, it becomes chronic – they know this now but disregard it.

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      2. canarensis

        ran across an article yesterday about how “Medication Overuse Headache” (which I think used to be called “rebound” headache) was enormously overdiagnosed, which seems to sorta tie in to the hyperalgesia –at least crabwise. It was great; vindication at last. I’ve had neuros claim that the ONLY reason I have headaches at all is because I treat them, which always leads me to ask why they started in the first place …the headaches knew I was GOING to treat them; headaches as psychic seers?? No doctor ever answered that question, unsurprisingly.

        As for undermedication causing hyperalgesia; didn’t they conclude a while back (during one of the Iraq wars) that undertreating acute pain could actually lead to chronic pain? If the pain pathways are active & you only partially shut them down, it seems not unreasonable that they could come back stronger, but that’s pure speculation, I guess.

        Parenthetically, I really hate pain studies done on animals being translated into human treatment. I realize you can’t mangle human subjects in order to study their pain unless you’re a Nazi doctor (tho God knows, I’ve got a list of candidates), but animal models are particularly crappy for this. When rats can clearly articulate how they feel, I’ll place a bit more confidence in the concept. (I worked with rats on a BP study, where I “merely” placed them into a little confinement box & put little BP cuffs around their tails. The BP ranges were all over the place from one minute or day to the next, for all of the rats. The only real conclusion that seemed to be discernible was, rats don’t like to be confined to a tiny dark coffin & have intermittent pressure applied to the base of their tails, & they react to it variably. This did not seem to be worth the time & effort put into it, nor the mental trauma of the rats and the experimenter. And –theoretically– they weren’t being physically hurt).

        That said, it’s sorta interesting the max hyperalgesia took place in the mid-range of the low dose (6μg out of 10 to 3 μg/kg range). At the lowest dose, it’s like not doing anything at all? thanks for the link.

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        1. Zyp Czyk Post author

          I had a series of pet rats for years and shudder at the cruelty of their animal kingdom position as overly fertile vermin seemingly intended mainly for the consumption of higher order predators – not to mention being used as almost “throwaway” lab specimens for all types of horrific experiments.

          They are truly like tiny dogs (except smarter and not as beholden to the humans that are feeding them). We let them run loose in the house when we were home and they entertained us with their interest, curiosity, and cleverness at exploring and gaining access to whatever we were trying to keep them away from (like going up the loft ladder). We had to design ever more complicated blockage contraptions that wouldn’t also block us from climbing up there.

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          1. canarensis

            I had a pet store for a while, & a number of people had pet rats that had frequent, & sometimes constant, free run of their houses. I liked one woman who told how her rat & dog would sit next toi each other while they ate, paws carefully not going over the line into the dining room, both bodies leaning wayyyyy over the line, as if the food might float over to them. She got lots of attention while driving or walking aorund with her rat perched on her shoulder –he went everywhere with her.

            I managed to avoid working with animals nearly the whole time I was a research technician. Getting that last job was a miracle (I’d been out of the lab for years), so I did it anyway. I absolutely hated it still get nightmares about it. The animal facility actually tried very hard to ensure that they were treated as decently as possible, but that “as possible” gets pretty flabby when you’re talking about animal experiments, no matter how carefully designed. But I did a lot of tissue culture work for years, & you just can’t replicate a whole organism or system with cultured cells. There is no good answer, I think…just shades of bad.

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