Last week more than 100 healthcare professionals and pain care advocates signed a letter urging the Department of Health and Human Services to “prohibit or minimize rapid, forced opioid tapering in outpatients.”
Other pain doctors declined to sign, however, arguing that the letter’s language was alarmist, and that involuntary taper is sometimes required.
Beth Darnall is the cheerleader for the theory that much pain is caused/maintained by “catastrophizing”, but now she seems distressed that her theory is being used to deny opioids to millions who need them.
My anger about her pushing her “catastrophizing” theory is dissipating quickly as she’s now changed her tune, urging great caution for the rapid opioid tapers instituted without regard to consequences.
I’m impressed that she, as a scientist, is reevaluating and adjusting her public position that most patients don’t need opioids. Now she has become an advocate for pain patients to retain their access to opioids.
It addresses the plight of chronic pain patients who have been prescribed very high doses of opioids but who—whipsawed by rapid changes in medical consensus about the risks and benefits of such medication—are suddenly finding that they can no longer obtain their medications at such dosages.
An estimated 18 million Americans are on long-term prescription opioid therapies.
That seems like an exaggerated number to me: almost a fifth of all Americans.
We would have to know what exactly they mean by “long-term prescription opioid therapies”: long-term for life with chronic pain or anything over a week, including healing from wounds or surgeries.
If these patients are deprived of their medications too quickly, with insufficient medical and psychological support, they will suffer excruciating withdrawal symptoms. As a result, they “may seek relief from illicit (and inherently more dangerous) sources of opioids” or “become acutely suicidal,” the letter says.
In 2016, the Centers for Disease Control and Prevention published guidelines urging doctors to exercise great caution before escalating opioid doses above a certain level—the equivalent of 90mg of morphine per day. Many pain patients were on far higher doses when the guidelines came out.
When those patients’ physicians retire, few doctors are willing to step into their shoes, continuing to prescribe opioids at such elevated levels.
Controversially, the Darnall letter asserts that “non-consensual tapering policies are being enacted throughout the country without careful systems that attend to patient safety.” These policies, it says, are being implemented by “prescribers and healthcare organizations, pharmacies, and insurance payors.”
“This is a large-scale humanitarian issue,” the letter states. “New and grave risks now exist because of forced opioid tapering: an alarming increase in reports of patient suffering and suicides within and outside of the Veterans Affairs Healthcare System in the U.S.”
“We’re imploring decisionmakers to think very carefully about unintended consequences,” says Darnall in an interview.
I do not believe these “unintended consequences” of instant opioid tapering in all pain patients were either unintentional or unforeseeable: CDC Opioid Guideline: Unintentional Consequences?
“Policies are being implemented that may seem beneficial, but can confer additional suffering on the most vulnerable patients. . . . I don’t believe there should be collateral damage.”
Prominent signatories include
- Darnall’s colleague Sean Mackey, MD, PhD, who leads Stanford’s pain medicine division;
- addiction specialist Stefan Kertesz, MD, of the University of Alabama, an outspoken advocate for chronic pain patients;
- addiction psychiatrist, Yale University School of Medicine lecturer, and writer Sally Satel, MD; and
- the presidents and past-presidents of several pain medicine professional societies in the U.S., Canada, and Australia.
The letter has been accepted for publication as a commentary by Pain Medicine, according to Darnall.
Advocates for chronic pain patients have submitted similar letters in the past, including two authored by Kertesz protesting proposed policy changes by the Centers for Medicare and Medicaid Services and the National Commission on Quality Assurance.
But Darnall’s letter gained at least two new, notable signatories from the ranks of those who champion reductions in opioid prescribing
These include Darnall’s Stanford colleague, psychiatry professor Keith Humphreys, PhD, and David Juurlink, MD, PhD, a prominent Toronto clinical pharmacologist and researcher, who is also a board member of Physicians for Responsible Opioid Prescribing—an organization widely reviled by chronic pain patients.
Darnall also sought signatures from PROP’s executive director and president, addiction psychiatrist Andrew Kolodny, MD, and pain medicine doctor Jane Ballantyne, MD, respectively. They circulated the letter to the organization’s 19-member board, but none, besides Juurlink, signed
“[Darnall’s letter] addresses a real problem,” Kolodny acknowledges in an interview, which he calls “the problem of legacy patients.” By that he means patients prescribed opioids in the past for conditions that science now shows are actually worsened by those drugs.
“What I don’t like is that [the letter] gives credence to a false narrative of government overreaction that’s resulting in policies all over the country forcing patients to come off opioids too rapidly, resulting in people committing suicide or using fentanyl or heroin.”
But that narrative is absolutely correct and easily proven. The changed trajectory of the “overdose crisis” is now about illicit drugs like fentanyl,
No matter how many times Kolodny spouts his severely outdated (and incorrect) theories that the problem is prescription opioids, the data clearly show this is not the case (and probably never was).
The letter was sent to the chief medical officer of HHS, Vanila Singh, MD, on Sept. 24, just before a two-day meeting of the HHS chronic pain task force. This week, Darnall gave a Congressional briefing and spoke with the FDA on related issues.
The letter concludes by asking that the agency take four actions:
- Enact policies that prohibit or minimize rapid, forced opioid tapering in outpatients taking legacy opioid prescriptions … ;
- Provide compassionate systems for opioid tapering, if indicated, that include … patient-centered methods … and realistic end-dose goals that are evidence-based … ;
- Convene patient advisory boards at all levels of decision-making … ;
- Require inclusion of pain management specialists at every level of decision-making ….
“Not every single patient on earth should go through taper,” says Darnall in an interview. “That’s just common sense. We need exceptions. Patients need to be protected.”
The following PROP board members agreed to share their concerns with the letter. Here are some excerpts:
- Mark Sullivan, MD (pain medicine doctor and psychiatrist at the University of Washington, who has published research on opioid tapering): “Voluntary and supported taper is always best. But the boundary between voluntary and involuntary tapers can be quite fluid in practice. Some of the highest risk patients really need to be pushed toward taper. Patients with diversion or [opioid use disorder] need to be forced to taper or switch to [buprenorphine, an addiction treatment medication].”
However, buprenorphine isn’t very effective for chronic pain and introduces other problems for pain patients:
- What Makes Buprenorphine Risky for Pain Patients
- Troubling aspects of Buprenorphine
- Opioid Antagonists in Chronic Pain Management
- Anna Lembke, MD (addiction psychiatrist at Stanford Medical School, who is currently leading a free, online continuing medical education seminar on opioid tapering): “I’m a strong advocate of slow, compassionate, patient-centered opioid tapers …. But I also believe these tapers need to occur even if patients don’t want them, i.e. in some cases, they need to be ‘forced’. … Data show the large majority of high dose legacy patients will not voluntarily engage in tapering.”
This kind of superior posturing is frightening in any doctor. She shows no concern at all for people living with constant pain.
- Stephen Gelfand, MD (rheumatology consultant, Myrtle Beach, S.C.): “Certainly the avoidance of forced tapering in most … is indicated. But there is also a significant percentage of these patients who actually have the disease of addiction and need addiction treatment services including medication-assisted therapy [MAT] such as buprenorphine.
He’s been drinking the Kolodny Koolaid, utterly convinced that anyone taking opioids regularly is addicted and not really in serious pain.
The problem here is the difficulty in identifying these patients, who are often in denial, and/or their doctors are often reluctant to make the diagnosis of addiction or unaware of its possibility. …
This is their trap: once they’ve diagnosed any pain patient with addiction, any protest or disagreement is classified as “denial of addiction”, and used as further proof that the patient is addicted.
In view of the above, we also need to have victim advocates who have survived and overcome the scourges of addiction as the result of opioid overprescribing to sit on these patient advisory boards at every level of decision-making.”
Again, this guy doesn’t seem to believe that legitimate pain patietns exist, and if they do, they certainly don’t factor into any of his ideas.
- Danesh Mazloomdoost, MD (anesthesiologist and doctor of regenerative medicine): “The wording [of the letter] feeds into a catastrophic vocabulary prevalent among chronic pain patients. …
Here Beth Darnall’s theory has penetrated so deep that this guy can’t even see, let alone acknowledge, that patients are being terribly harmed.
I regularly see patients who feel abandoned by their providers because of a sudden arrest in the opioids they had been prescribed for years. These patients have the impression that regulations, addiction, and physician fears of prosecution are the primary motivators for this radical change.
Is he so totally blind that he cannot see the truth of this?
They are entirely unaware of the scientific foundation that guides these changes ….
But there was no proper scientific foundation to the CDC guidelines, in which strong recommendations and arbitrary milligram limits were made with weak evidence.
It sets up an adversarial relationship with every clinician thereafter and further stigmatizes opioid use disorder and alternatives to opioid management.
Blinders firmly in place, he seems unaware of the stigmatization of pain patients as well. In fact, his opinion does not take legitimate chronic pain into account at all.
I would strongly urge a more objective letter outlining the need for clinician guidance on …
- how to effectively converse with patients about the long-term detrimental effect of opioids and the need for tapering, and
- methodological guidance on tapering.”
Pain does not even exist in this guy’s universe.