Clinical Challenge: Opioid Tapering

Clinical Challenge: Opioid Tapering | MedPage Today – by Judy George, Senior Staff Writer, MedPage Today March 1, 2020

Too much focus on the pill and not enough on the whole person: that’s a key piece missing in the movement to reduce opioids among chronic pain patients, said Beth Darnall, PhD, of Stanford University in Palo Alto, California.

Some agencies and companies used the 2016 guideline to push hard dose limits and abrupt tapering, which the CDC later said was inconsistent with its recommendations

I notice that this hasn’t changed any of the “wrong” laws, which may be enforced long after the truth is known.  

Last year, the FDA issued a safety announcement about sudden opioid tapering, and in the fall, federal health officials released a new guide to try to bring a more balanced approach to the tapering process.

But no one is listening because all the politicians are trying to out-do each other as ferocious drug-warriors. Very few seem to understand that medical opioids are NOT even a part of the problem (but the only part that can be measured).

For chronic pain patients, cutting back on opioids can lead to serious consequences, especially if tapering is non-consensual.

“These adverse effects may include

• failing to complete the taper,
• stopping care,
• overdosing,
• suicidal ideation,
• worsening of depression or anxiety, and
• increased use of hospital and emergency health services,” 

It sounds like some doctors are starting to see the fallout from these cruel restrictions on pain relief.

A recent retrospective study conducted by researchers in the Bronx, New York, for example, showed that compared with continuing long-term opioid treatment, pain patients who tapered their opioids were 4.3 times more likely to subsequently terminate care.

And a trial in Denmark that tried to evaluate sequential opioid tapering among long-term pain patients reported that the program failed due to a high number of dropouts.

“There’s no good system or structure to implement opioid reduction in a way that we have confidence in, that shows we’re supporting patients and improving their health and their lives,” Darnall observed.

“This is where the imperative comes in to focus on voluntary opioid tapering,” she said. “Let’s create the evidence base. Let’s start with a population where we can have the highest level of support and patient engagement.”

Darnall and colleagues conducted a small community-based trial of chronic pain patients who wanted to reduce opioid use.

So these patients wanted to reduce their opioid use before they even started the study. That’s a very small and preselected batch of patients certainly not representative of the “average pain patient”.

Of 82 patients in the study, 31 patients dropped out, which is not unusual for a study like this, Darnall noted.

I don’t know how she can say that having over a third of the subjects drop out of a trial is “not unusual”.

That makes me wonder about what she might mean by “a study like this”, perhaps one that causes subjects to suffer a lot of pain? That would certainly explain the extremely high rate of dropouts.

But for the 51 patients who finished, the median daily morphine milligram equivalent dropped from 288 mg to 150 mg, with no increase in pain intensity or pain interference. These people had been on opioids a median of 6 years before the study started.

That’s a <50% reduction, which is a far cry from the mandated forced quitting we’re seeing implemented all over the place.

Another big trial looking at opioid prescribing and tapering strategies focuses on 1,000 Veterans Affairs (VA) patients who have high levels of pain despite opioids.

That’s another very narrow group of patients who aren’t getting good relief from opioids anyway. This says nothing about all of us who DO get relief from opioids.

“Many patients don’t want to taper when they join the study, and we don’t require them to taper,” said study leader Erin Krebs, MD, MPH

But they ARE being forced to taper by the VA, so this makes no sense to me.

“Because opioid dose reduction is the right thing to do for most participants in the study — that is, risks outweigh benefits — study clinicians work to develop a collaborative plan that involves trying other pain management approaches and encourages engagement with tapering.”

If “other pain management approaches” worked, many of us wouldn’t need or even want the opioids that get us in so much trouble these days. If we could avoid opioid use, we certainly would:

Who would want to be treated like a drug addict? Who would volunteer to live in constant fear of being cut off and going into horrible withdrawals?

Opioid withdrawals are so serious they’re what keeps many heroin users using long after they want to quit, but no one seems to care if users of prescribed pain medications are sent into the same hell of withdrawal when our medication is simply stopped.

The goal is to help patients find pain management approaches to reduce their opioid use, Krebs emphasized.

“The primary focus really is on the pain management part of that,” she pointed out.

That’s a ridiculous statement to make when everything we read is measuring opioid milligrams, NOT effective pain management.

“Once you improve pain management and find better solutions, it’s easier to start backing off of opioids.”

Again, if there really existed better solutions for our pain, we wouldn’t even want to take these problematic opioids.