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”. 

Stanford Doc Says Opioids Necessary Sometimes

Here’s a very supportive Twitter posting from the leader of Stanford’s Pain Management efforts: Sean Mackey, MD, PhD.   (@DrSeanMackey) on Oct 22, 2019

This is a breath of fresh air! Coming from an influential leader in the pain management field at a high-status University, I have hope that it will get through to some of our tormentors.

1) I’d like to share this brief story about a patient who’s currently taking opioids.

2) We’ve been treating a patient at Stanford who has a lower extremity injury. He came to us on high-doses of opioids through fentanyl patches.  

His primary care doctor wanted him weaned off. He has tried every treatment imaginable.

And why did his primary doctor want him weaned off? The rest of this little story shows that there were no medical reasons to take the patient off opioids. 

Market barriers to appropriate pain management

AMA: Get rid of market barriers to appropriate pain management – by Andis Robeznieks – Senior News Writer – American Medical Association

This article makes a critical point and describes what should be the goal when treating pain: “appropriate analgesic prescribing and pain management.”  

Ending the nation’s opioid epidemic requires eliminating obstacles to treatment and appropriate analgesic prescribing and pain management.

New policies adopted at the 2019 AMA Annual Meeting took aim at barriers established by health plans and other players in the medical system. 

PROP eases absolutist stance on opioid prohibition

Opioid Dose Tapering, Opioid Dependence, and Indications for Buprenorphine | Annals of Internal Medicine | American College of Physicians – September 2019

This article is significant only because its authors are all founding members of PROP, the group that initiated, escalated, inflamed, and essentially fabricated the whole issue with prescribed opioid medication:

• Roger Chou, MD;
• Jane Ballantyne, MD;
• Anna Lembke, MD.  

I’m delighted to see even a tiny crack in the seemingly invincible force of opioid prohibition.

HHS Guidance for Dosage Reduction

HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Opioid Analgesics – Oct 2019

I’m furious that throughout this detailed 8-page document, the assumption is always that tapers must happen, one way or another. I couldn’t find a single sentence suggesting it may be best to leave patients on some dose of opioids for their pain because, for most of us, opioids are the ONLY effective means of pain control.

More judicious opioid analgesic prescribing can benefit individual patients as well as public health when opioid analgesic use is limited to situations where benefits of opioids are likely to outweigh risks.

Yet they never again mention this case of the benefit being greater than risks, even though that’s the case for so many of us.

Pain Awareness IS Suicide Prevention

Coincidentally, the month of September is “Pain Awareness Month” and its 2nd week is also “Suicide Prevention Week”.  I believe pain awareness *is* suicide prevention, so here is my yearly post about the unintended serendipity of these two awareness campaigns going on at the same time.

By now we have direct evidence that a lack of pain awareness, as demonstrated by all the politicians and healthcare “experts” enshrining the CDC “guideline” prescription opioid restrictions as law, is leading to suicides of patients with uncontrolled pain.

• Pain Experts Call for End to Forced Opioid Tapering
• Risk of Opioid Medication Discontinuation

Can the connection become any more obvious? 

Risk of Opioid Medication Discontinuation

Opioid medication discontinuation and risk of adverse opioid-related health care events. – PubMed – J Subst Abuse Treat. 2019 Aug

Between 2012 and 2017, the United States dramatically reduced opioid prescribing rates.

While this may be appropriate given the opioid epidemic, there has been little research to guide the clinical practice of discontinuing patients from opioid medications and opioid death rates have continued to increase.

These forced tapers have been a horrible experiment on thousands of people, enacted without any knowledge of what the outcome might be.  

Outcomes After Opioid Tapers: Time to Start Counting

Outcomes After Opioid Dose Reductions and Stoppage: It’s Time to Start Counting – Stefan G. Kertesz, MD, MSc – Aug 2019

As clinicians reconsidered the value of a muchoversold drug class [opioids], the institutions that govern, regulate, pay, and police health care pushed for reductions. 

The unanswered question[s] would be

• how such reductions would be carried out,
• who might measure the outcomes, and
• whether those outcomes included benefits, harms, or both.

And into that chasm of deliberate blindness are falling the suicides of pain patients who cannot live with their pain untreated.

Mortality After Discontinuation of Opioid Therapy for Pain

Mortality After Discontinuation of Primary Care-Based Chronic Opioid Therapy for Pain: a Retrospective Cohort Study. – PubMed – NCBI – J Gen Intern Med. – Aug 2019

BACKGROUND:

Despite known risks of using chronic opioid therapy (COT) for pain, the risks of discontinuation of COT are largely uncharacterized.

These “risks of discontinuation of COT” are not “largely uncharacterized” but rather completely unstudied.

Pain patients being tapered are being used as guinea pigs because those who are restricting opioids have no idea what the results might be. 

Patients left in anguish by doctors ‘terrified’ of addiction

Pain patients left in anguish by doctors ‘terrified’ of opioid addiction, despite CDC change – Ken Alltucker and Jayne O’Donnell, USA TODAY – June 2019

I’m encouraged to see this article in such a mainstream publication where it will be seen by more than just patients and their doctors.

The Centers for Disease Control and Prevention issued guidelines in 2016 to cut back prescriptions after years of liberal opioid dispensing contributed to addiction and overdose deaths. 

Those guidelines influenced more than doctors: State regulators, health insurers and even disability administrators have cited the federal guidelines to justify policies that limit pain pill prescriptions.