December 25, 2018
By Tamara Mathias
(Reuters Health) - Mandatory opioid tapers could sometimes do more harm than good, international medical experts warn in an open letter to health authorities.
The letter, published in the journal Pain Medicine, outlines risks associated with forced tapering of opioids and petitions U.S. policymakers to develop guidelines that are not "aggressive and unrealistic."
Nearly 18 million Americans are long-term opioid users because of chronic pain. In the wake of an opioid addiction crisis that has claimed thousands of lives, health regulators and the medical community have doubled down on reducing the number of opioid pills prescribed to patients.
The U.S. Centers for Disease Control and Prevention advocates tapering and, in some cases, discontinuing opioids in patients using them as long-term therapy for chronic pain.
However, in their letter, Beth Darnall of Stanford University in California and coauthors say mandated opioid tapers requiring "aggressive" dose reductions over a defined period, even when that period is an extended one, could be problematic.
They call for "compassionate systems for opioid tapering" in carefully selected patients, with close monitoring and realistic goals. They also call for "patient advisory boards . . . to ensure that patient-centered systems are developed and patient rights are protected."
"The assumption that forced opioid taper is reliably beneficial is not supported by evidence, and clinical experience suggests significant harm," said Ajay Manhapra of Yale University, who co-authored the letter.
For example, the letter notes, rapid forced tapering can destabilize patients, lead to a worsening of pain, precipitate severe opioid withdrawal symptoms and cause a profound loss of function.
Some patients may seek relief by sourcing illicit, and more dangerous, opioids, while others risk becoming "acutely suicidal", the paper adds.
"With the opioid tapering culture, pain specialists are making a killing," Manhapra said. "Our clinical experience is that with rapid tapers the healthcare costs go up due to excessive use of other costly services like emergency rooms and spine specialists."
"Whether it's a fast taper or a slow taper, the big question is - well, what do you do after that?" said Dr. Richard Blondell, vice chair for addiction medicine at the University at Buffalo in New York, who was not among the authors of the letter.
"What we really need is better science, not more politics . . . In my experience, when you have global recommendations based on expert opinions and you try to apply those to individual patients at individual clinics there's a lot that gets lost in translation."
The letter petitions the U.S. Department of Health and Human Services to consider patient data and include pain specialists when developing opioid tapering guidelines.
Manhapra believes the onus remains on policymakers.
"It appears that the storm blew one way from 1980's to 2016 and now it is blowing hard the other way, while we (doctors) stand staggering at the same spot trying to take care of our patients who are suffering," he said.
Pain Medicine 2018.
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