Pain Patients Shouldn’t Have Opioids Abruptly Tapered

Chronic Pain Patients Shouldn’t Have Opioids Abruptly Tapered, Says New Guidance : Shots – Health News : NPR – Oct 2019 – Heard on All Things Considered

In the haste to address the epidemic, there’s been pressure on doctors to reduce prescriptions of these drugs — and in fact prescriptions are declining. But along the way, some chronic pain patients have been forced to rapidly taper or discontinue the drugs altogether.

Now, the U.S. Department of Health and Human Services has a new message for doctors: Abrupt changes to a patient’s opioid prescription could harm them.

Adm. Brett P. Giroir, MD, assistant secretary for health for HHS. “If opioids are going to be reduced in a chronic patient it really needs to be done in a patient-centered, compassionate, guided way.”

I’m so glad they say “if” instead of “when”. 

Giroir says it’s concerning that some clinicians, policymakers, and health systems are “interpreting guidelines as mandates.”
“A guideline is a guideline it’s not a mandate or a rule that works for every single patient,” he says.

Entirely discontinuing opioids for a chronic pain patient is not always appropriate, according to the guidelines:

That’s another administrative and legal decision made by people who have no idea about patients and their pain and how they respond to medications.

“Unless there are indications of a life-threatening issue, such as warning signs of impending overdose, HHS does not recommend abrupt opioid dose reduction or discontinuation.”

The HHS will only say reduction or discontinuation, which still assumes that opioids must be tapered eventually.

HHS gives only two choices, reduction or discontinuation, and never mentions a 3rd possibility: maintenance.

They object only to it being done abruptly but never question the validity of their concerns over “safety” that seek to blame our opioids for all the people dying by overdose from a polydrug cocktail that almost always contains illicit fentanyl, an unprescribed opioid so potent that “just a little more” can kill.

Still, he says the evidence shows that “a majority of patients can have a reduction in opioids and improve pain control at the same time.”

I just can’t bring myself to believe this, that a *majority* of patients have less pain on a lower dose. My experience and that of so many patients I know completely contradicts this. We receive consistent and significant pain relief from opioids and if we take less, we hurt more.

I keep hearing about this counterintuitive phenomenon, though never from patients themselves, which makes me suspicious. It’s known that those without pain tend to minimize the pain of others, so this could be another study that’s been twisted by bias to reach the wrong conclusion.

And once an “expert” hears such a story that supports their belief system, they assume it true without checking for themselves and so keep repeating and spreading the lie without knowing they’re lying.
I know how this works in most of us because I’ve caught myself doing this too, and had to force myself to reconsider.

I want to hear from patients who are part of this “majority”, to find out how they managed to reduce their pain even as they reduced their pain-relieving meds.

That would be a true miracle for so many of us and I want to learn how to do it for myself.

A growing concern about prescribing rules

The new tapering guidance follows earlier efforts to signal that too much emphasis on reducing opioids for chronic pain patients may backfire.

Dr. Stefan Kertesz, a professor of medicine at the University of Alabama at Birmingham School of Medicine says, “We have to be concerned that the governmental and nongovernmental agencies continue to incentivize dose reductions that violate the precepts of this document and hold no one accountable for harm to patients when doses are forced down across the board,” says Kertesz.

There are two crimes here:

Our government (federal agencies) are conducting an experiment of forced opioid tapering on hundreds of thousands of citizens without their permission.

They are not measuring, documenting, or even observing the horrific outcomes of their experiment so that they don’t have to revise their hypothesis. They just keep insisting that restricting prescription opioids will lessen drug overdoses and decline any responsibility for the damage inflicted on innocent patients.

Clinicians across the country remain under immense pressures to curb prescribing. Kertesz notes that Medicaid, as well as states and private payers, still have policies that lead to forced dose reductions.

“Until those laws, regulations, quality metrics and criteria are revisited, we will have to live with a heart-breaking conflict between what well-intentioned experts think is good practice and what our health system and laws incentivize,” he says.

Kertesz says a growing body of research is undermining the “foolish assumption that because pills have gone down, safety has been created.”

“Taper might help some patients if you do it 100% correctly,” he says, “And in reality, we are mostly doing it wrong.”
Increasingly, patients with chronic pain are echoing these concerns as their doses are being lowered or discontinued.

Lessons learned from a Seattle clinic

The dangers of paring back opioid prescribing came into sharp focus for Dr. Joseph Merrill when his primary care clinic in Seattle tightened its rules around opioid prescribing nearly a decade ago.

The new policy at Harborview Medical Center aimed for a more cautious approach to prescribing the pills – measures like urine drug tests, dosing recommendations and guidance to taper patients on higher doses.

After the rules took effect, Merrill began to notice certain patients weren’t faring well. Some were missing appointments. Others appeared to be using illicit drugs or misusing their prescriptions.

Over the next five years, the clinic used an in-house registry to track 572 of its patients who were on chronic opioid therapy for pain. More than half had their opioids discontinued.

About 20% of the patients died during the study period of all causes. Close to 4% died of a definite or possible overdose and most of those were people whose prescriptions were stopped.

“The most concerning finding was that the group of patients whose opioid prescriptions were discontinued had a higher rate of overdose death than the group who stayed on their opioid medications,” Merrill says

Many of us have known this all along, yet it’s convenient for the media to keep ignoring it and keep pretending that restricting prescriptions will “fix” the “opioid crisis”.

The study doesn’t make a direct link between discontinuing opioids and someone dying from an overdose. But Merrill sees it as a warning about the risk of cutting off certain patients who have been prescribed opioids regularly for months or years.

“We did not prevent the death rate from going down by our practices,” he says.

There remains “a huge gap” in research about how the policy shift away from opioids is affecting patient outcomes, says Tami Mark who’s senior director of behavioral health financing and quality measurement at RTI International, a research institute based in North Carolina.

The outcomes of forced tapers fall into this inexcusable “gap”.

Mark coauthored a study published in The Journal of Substance Abuse Treatment earlier this year which examined what happened to patients in Vermont’s Medicaid program when they were tapered off high doses of opioids.

About half of the patients who were discontinued later experienced an opioid-related hospitalization or emergency department visit.

At the Seattle clinic, Dr. Merrill says their findings on the risks of discontinuing certain patients did prompt new protocols.

In fact, the newly released HHS guidelines tell doctors to consider switching patients who are struggling with a taper to buprenorphine, even if they don’t qualify as having a substance use disorder.

In the big picture, Merrill says, the seesaw in opioid prescribing – from liberal dispensation to the current climate of restriction – needs to stop.

And here’s another article illuminating our troubles with the guideline:

CDC’s Opioid Guidelines Have Been Misinterpreted, HHS Warns – LegalReader.com – Sara E. Teller — October 22, 2019

HHS is warning that “abrupt changes to a patient’s opioid prescription could harm them.”

The agency issued new guidelines for physicians on how best to manage opioid prescriptions utilizing a “deliberate approach to lowering doses for chronic pain patients who have been on long-term opioid therapy” rather than abruptly reducing assistance.

“It must be done slowly and carefully,” says Adm. Brett P. Giroir, MD, assistant secretary for health for HHS. “If opioids are going to be reduced in a chronic patient it really needs to be done in a patient-centered, compassionate, guided way.”

Giroir said it’s a matter of some practitioners “interpreting guidelines as mandates.”  He added, “A guideline is a guideline it’s not a mandate or a rule that works for every single patient.”

Especially now that healthcare has become so corporate, processes have been standardized so they can use metrics to evaluate and grade all their underlings. 

“There is a very large body of data across the scientific and medical literature that would say that abrupt discontinuation or abrupt reduction in dosage can be harmful to patients,” says Giroir

Dr. Stefan Kertesz, a professor of medicine at the University of Alabama at Birmingham School of Medicine said, “We have to be concerned that the governmental and nongovernmental agencies continue to incentivize dose reductions…and hold no one accountable for harm to patients when doses are forced down across the board.”

It was always strange that the outcomes of this great social experiment weren’t recorded to be evaluated. Even now, over three years past the guidance, we are still seeing more laws and rules being handed down to prevent opioid prescriptions as though they were the problem.

Anyone who bothers to look at the data however will notice that prescription opioids are found less and less in the people who overdose.

More and more it is fentanyl that’s killing people who overdose.

And this is not fentanyl made in an FDA approved laboratory, this is illicit fentanyl cooked up at some grubby chemist’s basement in Mexico or China. This is a drug that can kill with a few milligrams and it’s easy to mix in just a little too much of this cheap drug and kill people.

Kertesz added that Medicaid, as well as state and private payers, still have policies that lead to forced dose reductions, stating, “Until those laws, regulations, quality metrics and criteria are revisited, we will have to live with a heart-breaking conflict between what well-intentioned experts think is good practice and what our health system and laws incentivize…Taper might help some patients if you do it 100% correctly.  And in reality, we are mostly doing it wrong.”

I noticed he said taper MIGHT help SOME patients and I believe this is the reality, not tapers WILL help ALL patients.