Illicit opioid use after loss of access to opioids for pain

Illicit opioid use following changes in opioids prescribed for chronic non-cancer pain. PLOS ONE. May 4, 2020.

Here’s a finally a study showing the potentially hazardous actions taken by pain patients when their pain relief is cut off. I’m surprised they found the same thing with increasing the dose – if anyone can think of an explanation, please let me know.

In a retrospective study of more than 600 patients in San Francisco receiving opioid pain relievers (OPR) for chronic, non-cancer pain, the researchers found that

• “[l]oss of access to prescribed OPRs was associated with more frequent use of non-prescribed opioids and heroin, and
• increased OPR dose was associated with more frequent heroin use.

In addition to being cautious with increasing OPR dose, care providers should consider the potential unintended consequences of stopping OPR therapy when developing opioid prescribing guidelines and managing practice.”

Guide to tapering opioids seeks balanced prescribing

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.

One-Size-Fits-All Regulations Can Be a Straitjacket

Governors Discover One-Size-Fits-All Regulations Can Be a Straitjacket—The Same Is True With Pain Prescription Limits | Cato @ Liberty – By Jeffrey A. Singer – Mar 2020

The 2016 guidelines for the treatment of acute and chronic pain issued by the Centers for Disease Control and Prevention, like Medicare’s CRNA regulation, were always meant to be optional. In fact, in its opening section, the guidelines state:

“Clinical decision making should be based on a relationship between the clinician and patient, and an understanding of the patient’s clinical situation, functioning, and life context.”

This is the part that everyone is ignoring but will come back to haunt us when more and more of medicine is standardized. This COVID crisis is exposing how disorganized and broken (but always profitable!) our healthcare system is. 

More Veteran Suicides Than Combat Deaths

Time to Bring the Troops Home: More Veterans Committed Suicide Last Decade Than Died in Vietnam – by Matt Agorist – Mar 2020

I knew there was a high rate of suicide among veterans since pain medications have been restricted, but I had no idea that those on active duty are also dying from suicide (though I’m not terribly surprised).

It is no secret that the leading cause of death among active duty troops deployed to the Middle East is not combat or accidents, or IEDs — it’s themselves.

The Pentagon’s own statistics show that this is a crisis but it is being ignored.  

This crisis is also happening in the civilian population. No one is making the logical connection between forcing so many Americans to give up effective pain relief and the increasing numbers of suicides. 

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.  

Life (Plus a great deal of Pain) after Opioids

Life after opioids: ‘I went home and cried for a long time. I felt really stupid’ | Australia news | The Guardian – by Celina Ribeiro – Feb 2020

Ms. Ribeiro has written an excellent two-part article on our plight:

For people managing chronic pain, the push to reduce opioid prescription has left them feeling lost and unsupported.

…and with untreated, extreme, and suicide-inducing pain.

Louisa O’Neil inhales deeply when she is asked about her history of pain. Then, dispassionately, like recalling a string of part-time jobs, she lists the history of surgeries, injuries, accidents and conditions that have rendered her in a near permanent state of pain for the past 16 years.  

Ontario (Canada) Ends Forced Opioid Tapering

Bravo Ontario; Forced Opioid Tapering is (Mercifully) Ending | American Council on Science and Health – By Josh Bloom — January 30, 2020

Let’s hear it for Dr. Nancy Whitmore, the head of the College of Physicians and Surgeons of Ontario. She has the ethics and the courage to make changes in policy that should have never been in place to begin with.

Barbaric forced tapering will no longer be permitted, and doctors and patients will make treatment plans together.

Hallelujah!! Finally, some common sense and courage in the face of the anti-opioid politics dictating medical care these days. 

Even Medical Lit Subject to Media Hype about “Opioid Crisis”

Are Prescription Opioids Driving the Opioid Crisis? Assumptions vs Facts | Pain Medicine | Oxford Academic – Mark Edmund Rose, BS, MA – Dec 2017

Sharp increases in opioid prescriptions, and associated increases in overdose deaths in the 2000s, evoked widespread calls to change perceptions of opioid analgesics.  Medical literature discussions of opioid analgesics began emphasizing patient and public health hazards.

Repetitive exposure to this [mis-]information may influence physician assumptions.

This is a huge problem for us, and a sad commentary on the state of medicine in the U.S. when doctors are influenced more by media-hype and biased research than their patients’ lived experiences. 

A Practical Approach to Opioid Weaning

A Practical Approach to Opioid Weaning in the Midst of an Opioid Crisis – Pain Medicine News – by Mary Milano Carter, MS, APRN-BC, RN-BC – Sep 2019

The expanse of chronic pain in the United States is incredible. According to U.S. government statistics, pain affects more people than diabetes, coronary heart disease or cancer.

Low back pain gets the gold medal here, affecting 27% of individuals with chronic pain, per the National Institutes of Health.

Approximately 26 million Americans between 20 and 64 years of age experience frequent episodes of low back pain, and it is the leading cause of disability in Americans under 45 years of age, according to the AAPM.

As providers, we struggled to treat our patients’ complaints of debilitating pain, and sales of prescription opioids quadrupled between 1999 and 2014.

Treating benign pain with opioids became an accepted part of the treatment plan, keeping in mind the need to satisfy the Joint Commission’s standards for pain management.

In 2016, the “CDC Guideline for Prescribing Opioids for Chronic Pain” stated that opioids should not be prescribed as first-line treatment for chronic pain, and that prescriptions should be kept to 90 mg of morphine or less daily, or the equivalent in another opioid

No, it did NOT say to keep rx at 90mg or less – it merely said to be more cautious.

Unfortunately, a guideline that was aimed at primary care providers became a standard of care to insurance companies. Providers had to comply with weaning patients on opioids to satisfy the CDC guideline

But the guideline never mentioned anything about weaning. In fact, it said nothing about patients already taking opioids.
It’s all the other people/agencies meddling with our meidcal care that unilaterally decided to wean current patients.

Pain management providers have been adept at weaning patients from opioids due to severe side effects, patient noncompliance with treatment, unsafe patient behaviors, lack of efficacy of the medication or just simply patient desire.

But most patient being weaned don’t exhibit these wigns of opioid use disorder. It seems Ms Carter is saying that while they’ve always had to wean people who had problems with using opioids or their efficacy, now they “had to” wean patients for no other reason than to satisfy bureacracy or managers they are working under.

The Process of Tapering

How long does it take for a patient to become opioid tolerant?

The FDA definition is a patient taking 60 mg of oral morphine daily, or the equivalent of that in another opioid, for at least one week.

If a patient discontinues abruptly or is tapered down rapidly, withdrawal symptoms can occur.

The National Institute on Drug Abuse states that the length of withdrawal symptoms is dependent on

• how long the drug was taken,
• the dosage of the drug,
• the half-life of the drug,
• the patient’s age and
• comorbidities.

And NIDA (the agency with extensive history and expertise on drug abuse) helpfully explains the journey through withdrawal:

• The typical onset of withdrawal is approximately 12 hours, starting with myalgias and excessive yawning.
• By day 2, hyperhidrosis, anorexia, diarrhea, runny nose, and anxiety and panic attacks can occur.
• By the third or fourth day, the patient can experience abdominal cramping and vomiting while the myalgias begin to subside.
• By days 5 to 6, most of the physical symptoms will resolve, but the psychological symptoms can be long-lasting (Table).

Table. Opioid Withdrawal Symptoms 

When initiating an opioid taper, alert the patient that the process typically takes two weeks to six months—and sometimes up to 24 months, depending on opioid usage.

The total daily dose of opioids can be reduced 10% to 20% every one to two weeks, and reduced up to 50% at a time if the dosage is low or truly as needed.

Dies this mean opioids were used when they were *not* needed?

If the dose of a medication is taken truly “as needed”, this statement means the patient is suffering from symptoms that medication can ameliorate.

This seems a clear medical reason to continue the medication. Otherwise, a doctor is literally deprescribing a medicine that was medically needed.

When the total daily dose becomes very low, it should be reduced by 5% at a time.

It is important to monitor the patient closely for withdrawal symptoms, and individualize the plan of care.

When performing an opioid taper without a medical reason, only because of outside influences, how can that be individualized? When a patient needs a medication, treating them as an individual would mean continuing to prescribe the needed medication.

If the patient is reporting withdrawal symptoms, you can use the Clinical Opiate Withdrawal Scale.

Eleven symptoms are graded and tallied, and total score will indicate mild to severe opioid withdrawal (Figure).

Figure. Clinical Opiate Withdrawal Scale.
Based on J Psychoactive Drugs. 2003;35(2):253-259.

Medication therapies to assist with weaning and withdrawing opioids include:

• lonidine (physical withdrawal symptoms, decreases sympathetic activity)
  – mg po bid; Catapres TTS1 patch
• nonsteroidal anti-inflammatory drugs/acetaminophen (pain)
• loperamide (diarrhea)
• melatonin or trazodone (sleep)
• prochlorperazine (nausea and vomiting)
• hydroxyzine (anxiety)
• oxybutynin (sweats)
• antidepressants
• antiepileptics

The patient should be reassessed every three to seven days. It is not recommended to treat withdrawal symptoms with other opioids or benzodiazepines.

How is a patient, crippled by pain, going to get to the doctor every 3 to 7 days? How can a disabled patient afford so many appointments?

Most of the suggested drugs have already been prescribed to pain patients to lower the dose of opioids needed.

There are also adjuvant therapies to assist with opioid weaning.

Nondrug management can include

• support groups and counseling,

What if your pain doesn’t respond to talk therapy because it has a physical cause?

• Referrals to detox/addiction medicine/psychiatry, 

No matter how prettily they dress it up we see here that they think we’re all more addicted than in pain.

• nutrition and hydration counseling, 

So now our disabling chronic pain might be due to not drinking enough water? To not eating the right food?

• good sleep hygiene, 

What if your sleep is horrible *because of* your pain? What if you can’t sleep because you’re no longer given proper pain relief?

• relaxation and meditation, 

The modern “cure-all”: you’re hurting because you’re stressed and if you’d just learn to relax, you wouldn’t be having so much pain. Condescending, minimizing, 

• Reiki therapy, 

Now a medically trained doctor is expected to promote “mystical” alternative therapies? Seriously?

• aromatherapy, 

If a patient has pain severe enough to need opioids, aromatherapy will not be effective.

• an exercise regimen. 

What if you can’t exercise *because of* your pain? What if tapering causes your pain to increase, and then you can no longer exercise? (that’s my case: the less opioid, the more pain, the less exercise – I doubt I’m unique in that aspect.)

Also, most of these non-opioid therapies are already being used on pain patients in addition to their opioids.

The American Society of Addiction Medicine also has guidelines for opioid withdrawal. 

Again, patients are assumed to be addicted.

Recommendations include the use of:

• clonidine to support opioid withdrawal;
• methadone for patients who may benefit from daily dosing;
• oral buprenorphine, initiated after withdrawal, although it has poor medication adherence;
• oral buprenorphine-naloxone, initiated until 12 to 18 hours after the last dose of a short-acting agonist; and
• naltrexone for extended-release injectable suspension (Vivitrol, Alkermes) for those with difficulty adhering to oral daily doses.

In conclusion, clinicians should be aware that there are many options for safely weaning patients from chronic opioid therapy.

I wish they’d explain more about the basic assumption that all patients on opioids MUST be tapered. 

There are many patients who use opioids responsibly and only use them as needed for pain, but they are never mentioned. It’s as though it’s no longer legal to treat legitimate pain with effective medication.

Author: Ms. Carter is a member of the Pain Medicine News editorial advisory board.
Director of Nursing Education, Chronic Pain Service/Anesthesiology, North Shore University Hospital, Manhasset, N.Y.

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”.