Getting off opioids can be a crisis itself — so patients and prescribers need strong support.

By Travis N. Rieder

Dr. Rieder is the author of “In Pain: A Bioethicist’s Personal Struggle With Opioids.”

  • Oct. 31, 2019

In recent years, chronic-pain patients on long-term opioid therapy have been living in fear. They fear being abruptly cut off from their medication by doctors who no longer feel comfortable prescribing opioids. They fear the prospect of withdrawal and a life of pain.

We now have evidence that these fears are eminently reasonable. Across the country, clinicians have changed their prescribing practices, requiring that patients taper abruptly to a lower dose or discontinue their opioid medication altogether, sometimes under threat of being “fired” from their clinic if they don’t comply.

I know this not only from media reports but also from recent acknowledgment of the problem from the Centers for Disease Control and Prevention and Food and Drug Administration. I also know it because patients tell me. Ever since I went public with my own account of opioid dependence and the horror I experienced in withdrawal, I’ve collected heartbreaking stories from desperate patients. I’m approached after talks by audience members who want to share intimate details of their loved ones’ pain, medical histories and eventual abandonment. Other patients send me emails or handwritten notes, desperate for advice to relieve the pain and withdrawal they’ve been left in.

This is not how cases of long-term opioid therapy should be handled; our fear of opioids should not lead clinicians to abandon or forcibly taper their patients. Fortunately, the Department of Health and Human Services has now officially agreed, issuing a Guide for Clinicians on the topic of opioid tapering. The purpose of the guide is actually twofold: It teaches clinicians how to taper chronic opioid therapy (something for which there is a clear need), but it also directs clinicians not to taper opioids abruptly and nonconsensually (and not to abandon opioid therapy patients altogether).

It’s worth noting how strong a stance the department is taking with this second part of the guide. A central problem with pain medicine today is that there is a population of patients who, thanks to a history of aggressive use of opioids for chronic pain, are on high doses of opioids. Evidence now suggests, however, that many such patients probably never should have been taking such high doses. So what to do? Many patients are terrified of tapering, because — as I know well — withdrawal can be hell. But many doctors have felt they were supposed to taper them anyway, because the message they hear is “no high-dose opioid patients.”

The new guide directs clinicians not to force their patients to taper or to dismiss them from care (not to “fire” patients), because doing so may actually result in more harm than good. Although it can be beneficial to collaborate with a patient on a slow and careful taper, unilaterally reducing a patient’s dose can cause harm by forcing withdrawal or by incentivizing a switch to illicit drugs.

The department’s guide, then, is a hugely important document, and every clinician should take note. It does not, however, solve the problem it was designed to address. Doctors did not suddenly decide to begin rapidly de-prescribing opioids over the past few years — they were pressured to, by various forces in their community. Without addressing these forces, we can discuss the inappropriateness of current pain practices all we want, but we will not see significant progress.

Consider the environment set by state policies and guidelines. As of September 2019, 36 states have adopted prescribing limits that require clinicians to prescribe no more than a certain number of days or a certain dose. Although many of the laws target acute pain specifically and others have exceptions for certain forms of pain (like cancer pain), utilizing those exceptions requires high confidence that one is allowed to practice in a certain way, alongside the knowledge and willingness to perform extra steps to authorize the intended dose.

This overall environment is then combined with threat of enforcement. In Wisconsin, for instance, Justice Department attorneys sent letters to more than 180 prescribers, informing them that they were prescribing opioids at relatively high levels and that doing so irresponsibly could both worsen the drug overdose epidemic and open them up to criminal prosecution.

In other states, such as North Carolina, medical licensing boards have begun investigating high-dose prescribers. Even if most doctors are not reprimanded as a result, being called before the medical licensing board — like receiving a letter from the attorney general — can have a significantly chilling effect on one’s willingness to continue prescribing high-dose opioids. It is not surprising that North Carolina doctors admit to feeling pressured to taper high-dose opioid patients and to not accept new patients on high doses.

So clinicians are not making prescribing decisions in a vacuum; they are responding to policy and cultural pressures that were designed precisely to encourage reduced prescribing. If the goal of such mechanisms is to reduce only inappropriate prescribing, then they must be redesigned, because right now they are having an indiscriminate chilling effect that is harming patients.

The Health and Human Services Guide is a good step in the direction of compassionate, patient-centered care. But it will not by itself reverse practices that were formed as a response to structural forces. Responsible medicine requires a policy landscape that allows and encourages prescribers to do what is right, without fear of losing their medical license or their freedom.

Travis N. Rieder, the assistant director of education initiatives and research scholar at Johns Hopkins Berman Institute of Bioethics, is the author of “In Pain: A Bioethicist’s Personal Struggle With Opioids.”

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