Stopping Rx Opioids Associated with Death

Study: Stopping Long-Term Opioid Prescriptions Associated With Veterans’ Deaths – Filter Magazine – By Staff – Mar 2020

For years, pain patient activists have been sounding the alarm about the consequences of abruptly halting people’s access to opioid analgesics…

And we have not just been whining and complaining about our increased “biopsychosocial” pain. The physical and mental impact of experiencing unrelieved, constant, chronic pain can be overwhelming. The danger of forced tapers is an extremely serious and urgent problem, which is increasingly…

…supported by much research.  

A new addition to the body of evidence suggests that patients who have been treated the longest are at the greatest risk of fatal overdose and/or suicide after having their meds withdrawn.

The Veterans Health Administration (VHA) drastically cut its opioid prescribing in half within the first fiscal year of its 2013 Opioid Safety Initiative.

In that time year, 2,887 patients died from suicide or overdose, a March 4 study [link and excerpts below] found.

How can a patient overdose on a medication they are no longer receiving?

The overdoses are most likely from patients desperate enough to seek out illicit versions of the pain-relieving drugs they needed.

But unlike prescribed opioids, there’s no way to determine the exact ingredients or correct dose of illicit drugs, so these patients could easily be poisoned and overdose on illicit opioids.

Just like the CDC combining counts of prescription and illicit opioids, the VHA deliberately combines the counts of suicides and overdoses to hide the most pertinent fact:

Forced prescription opioid reduction and cessation cause suicide, not overdose.

This seems so obvious to me – what am I not understanding?

The study authors found a “significant interaction between stopping treatment with opioids and length of treatment.” The biggest proportion of veteran patients whose medication was ended had been on treatment for more than 400 days, the largest time period category—and they also faced the highest risk of death.

The fatal potential of being cut off from pain treatment is far from a new discovery.

The VHA itself advises that “[a]brupt discontinuation should be avoided unless required for immediate safety concerns.”

The Food and Drug Administration (FDA) has flat out rejected sudden termination of opioids, instead recommending the use of “a patient-specific plan to gradually taper the dose of the opioid and ensure ongoing monitoring and support.”

There’s evidence to suggest that the VHA was not doing everything it could to prevent these deaths.

Does doing nothing but defend its cruel, careless, and irresponsible actions count?

Multiple federal agencies (and several courageous doctors) have warned that stopping opioid prescriptions for no other reason than bureaucratic policy is medically inappropriate. I don’t understand how this is not malpractice when the individual characteristics of each patient’s case are not taken into account when determining medical treatment.

Even after all these warnings, the VHA (and many, many other medical organizations) have implemented mandatory measures to restrict and even stop prescribing opioids, for all patients and all pain, no matter the medical need for them.

the VHA in fact had a predictive model designed to estimate a patient’s risk of experiencing a “serious adverse event,” specifically meaning an overdose or suicide attempt—yet doctors were not providing required interventions for the most high-risk patients between at least 2016 and 2017.

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Below is the link to and excerpts from the actual study:

Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation | The BMJ – Mar 2020 (free full-text)

Objective

To examine the associations between stopping treatment with opioids, length of treatment, and death from overdose or suicide in the Veterans Health Administration.

Participants

1,394,102 patients in the Veterans Health Administration with an outpatient prescription for an opioid analgesic from fiscal year 2013 to the end of fiscal year 2014 (1 October 2012 to 30 September 2014).

Main outcome measures

A multivariable Cox non-proportional hazards regression model examined death from overdose or suicide,

I cannot fathom why these two causes of death were not separately counted.

with the interaction of time varying opioid cessation by length of treatment (≤30, 31-90, 91-400, and >400 days) as the main covariates.

Stopping treatment with opioids was measured as the time when a patient was estimated to have no prescription for opioids, up to the end of the next fiscal year (2014) or the patient’s death.

Results

2887 deaths from overdose or suicide were found.

I’m so frustrated by their refusal to count overdoses and suicides separately when they come from such different situations: no opioids at all versus illicit opioids. What a terrible choice to face.

The incidence of stopping opioid treatment was 57.4% (n=799 668) overall, and based on length of opioid treatment was 32.0% (≤30 days), 8.7% (31-90 days), 22.7% (91-400 days), and 36.6% (>400 days).

The interaction between stopping treatment with opioids and length of treatment was significant (P<0.001); stopping treatment was associated with an increased risk of death from overdose or suicide regardless of the length of treatment, with the risk increasing the longer patients were treated.

Descriptive life table data suggested that death rates for overdose or suicide increased immediately after starting or stopping treatment with opioids, with the incidence decreasing over about three to 12 months.

Conclusions

Patients were at greater risk of death from overdose or suicide after stopping opioid treatment, with an increase in the risk the longer patients had been treated before stopping.

Descriptive data suggested that starting treatment with opioids was also a risk period.

They insist on wording that makes it sound like both starting and stopping pain relief causes the same outcome when that is virtually impossible.

Older age, female sex, and being married were independently associated with a lower risk of death from overdose or suicide.