A new guide to tapering opioids seeks a balanced approach to prescribing – By Andrew Joseph @DrewQJoseph – October 10, 2019
Federal health officials on Thursday released a guide for clinicians who are considering tapering patients’ opioid prescriptions, highlighting the benefits of safe reductions in dosages while warning against abrupt drops for people who have been on the drugs for long periods.
The recommendations come amid concerns that some chronic pain patients’ dosages have been unsafely pulled back and that providers have sometimes abandoned patients.
Some experts and advocates have warned that overly aggressive reductions or forced cutbacks have led some patients who are dependent on the drugs to seek out illicit sources of opioids or consider suicide.
Prescribing levels have dropped since 2012, and some advocates have warned that the fear around opioids has left some patients unable to get them.
The new guide marks the government’s attempt to strike a balance between reducing the amount of opioids prescribed and ensuring patients aren’t left behind.
It also reflects concerns that prescribing guidelines released by the government in 2016 were misapplied and contributed to inappropriate tapers.
“It is a false choice to say we can only limit opioid use disorder, or addiction, or have pain control,” he said.
Overall, the guide casts the decision to taper as an individualized one that prescribers and patients should reach together.
Tapers may need to go slowly and their effects should be reviewed throughout the process. Patients need to have their concerns addressed, the guide stresses. It even suggests clinicians reiterate to patients that, “I’ll stick by you through this,” and to offer other forms of support.
Successful tapers to lower dosages can lead to improvements in sleep, mood, and overall daily function without leading to a resurgence of pain, according to the guide. But it also describes the risks of rapid tapering on the first of its six pages.
On the call with reporters, Dr. Deborah Dowell of the Centers for Disease Control and Prevention said there are not specific targets that dose reductions should try to hit.
Instead, patients and clinicians should find doses where the benefits of opioid use outweigh the risks.
“Tapering success does not mean getting down to zero or to any particular dose,” Dowell said.
The CDC suggested that prescribers “work with patients to taper opioid to lower dosages or to taper and discontinue opioids” in cases where the harms of taking the drugs outweigh the benefits.
But after the guidelines came out, insurers, pharmacies, states, and law enforcement agencies started cracking down on high prescribing, often pointing to the guidelines as the source of their policies.
Dowell (who is one of the authors of the CDC guidelines), Giroir, and Dr. Wilson Compton of the National Institute on Drug Abuse also wrote a piece in JAMA Thursday describing the tapering guide. In it, they write that “clinicians have a responsibility to provide care for or arrange for management of patients’ pain and should not abandon patients.”
Andrew Joseph
General Assignment Reporter
Andrew is a general assignment reporter.
andrew.joseph@statnews.com
@DrewQJoseph
EDS and Chronic Pain News & Info 
You know things have hit a bottom ledge when MDs have to write in a med journal that physicians should not abandon their patients. That really seems like it’d be part & parcel of medical care. Even if they no longer take the Hippocratic Oath, “don’t toss your patients out on an ice flow to die a slow, painful death” seems sorta obvious. Maybe it’s just me.
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No, it’s not just you. I notice that many of the directives on treating pain tell doctors just to really BE doctors.
It’s only the limits on opioids cooked up by anti-opioid zealots that are crazy – the rest of the guidelines just demand doctors do their job correctly: try least invasive pain treatments first, one after another, gradually moving up the risk and impact scale until reaching the point where only opioids remain. Only at that point do the guidelines commit their atrocity: limiting opioids to some “standard dose limits” or disallowing them completely.
This is the gauntlet I plodded through for 2 years, trying all kinds of medical, pharmaceutical, and “alternative” treatments. I spent thousands of dollars (over $20,000 in 2 years), which I thought I’d recoup once my pain was relieved and I could start working again. I was lucky to be working with a neurologist who understood that I needed opioid pain relief, at least temporarily, to undertake this project, for many long drives to different specialists, for waiting in waiting rooms or lines to get prescriptions, for the ability to do physical therapy exercises that kept my body from breaking down even more.
The assumption was always that we’d find a treatment that was effective for my my pain so that I could stop taking opioids. That never happened.
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