Published February 7, 2023
Yet another study from the University of California at Davis, examining tapering among adults prescribed stable doses of long-term opioid therapy (LTOT). These patients were receiving long term opioid therapy at a dose of 50 milligram of morphine equivalents (MME) or above per day, during a 12-month period. The study included 113,604 patients, and 41,207 and 23,335 had hypertension and diabetes, respectively.
The researchers found that opioid tapering was associated with “unintended negative consequences,” including more ED visits and hospitalizations. Tapering was also associated with fewer primary care visits, and therefore poorer adherence to both diabetes and hypertension medications.
It’s very clear that a forced opioid taper fractures the primary care relationship, but whether that’s because the patient has lost faith in the doctor, and no longer trusts the doctor’s judgement, or worse, the doctor has ‘fired’ the patient and refused them primary care due to their opioid use, is not clear. Either way, this leaves the patient no option for health care other than attending the emergency department.
In the US in recent years, it has been very common for doctors refuse to treat people on long term opioid therapy leaving them with no primary care provider. This scenario is also increasing in Australia, with many people on long term opioid therapy reporting difficulty finding a new GP, or primary care doctor, when their current doctor retires, or they move to a new location.
This is discrimination, plain and simple. Discrimination borne of stigma and a false narrative that is NOT based on the evidence, yet constantly promoted in the media and in government and medical journals and other publications.
The truth is that overdose is very rare in the chronic pain population and there is rarely a need to taper people who are stable on long term opioid therapy. Yet forced tapers are common, due to misguided Australian government policy that blindly follows the US model, despite the US model having been shown to have done great harm to people living with severe, daily pain.
There is now huge stigma attached to people living with severe, daily pain who require long term opioid therapy, and increasingly, doctors are refusing to take these patients on, perceiving them as difficult, complex and time consuming. I have experienced this situation myself, and anecdotally, the incidence is rising. Online forums are filled with tales of people being unable to find a new GP who will continue to prescribe their long-term opioid therapy and being thrown into withdrawal.
While doctors should be able to have choice in what kind of medicine they specialise in, it is unethical to refuse to take on patients who depend on long term opioid therapy. Or to take them on, but only under the condition that they taper their safe and effective opioid pain-relieving medications. Study after study has shown that forced tapering causes far more harm than maintaining stable long term opioid therapy, yet the prevailing belief in medicine is that opioids should never be prescribed long term. This is a belief, not a fact, and not based on the evidence.
Another reason GPs are reluctant to take on a patient on long term opioid therapy is the additional monitoring of their practice that opioid prescriptions attract and the fear that they may have conditions placed on their prescribing rights. The Australian government has conducted a scare campaign and fed lies based on old, outdated, low quality and flawed research. The result being that some doctors are choosing the easiest way to deal with the problem, and that is to avoid the problem by refusing to prescribe. Leaving people who live with severe, daily pain to suffer.
Additionally, many patients on long term opioid therapy have multiple chronic health conditions and diseases that require monitoring and comprehensive primary care. When doctors abandon these patients, they are condemning them to a lower quality of life, but also a shorter life span.
The researchers acknowledge this very succinctly, stating that tapering “may disrupt clinical stability” increasing the risk for overdose, suicide and worsened pain control and diminished patient trust.
But will the media pick up this message and will doctors and pharmacy journals and online magazines promote the harms of forced tapering?
I doubt it. I’ll be thrilled to be proven wrong, however.
It’s disappointing that the researchers conclude rather banally:
In this cohort study of patients prescribed LTOT, with subcohorts of patients with hypertension or diabetes, opioid tapering was associated with increased ED visits and hospitalizations and reduced PC visits for a general cohort of patients prescribed LTOT. Decreased medication adherence and worsened chronic condition control among patients with hypertension or diabetes were also noted. Although cautious interpretation is warranted, these outcomes may represent unintended negative consequences of opioid tapering in patients who were prescribed previously stable doses.
The evidence is very clear – forced tapers result in poorer outcomes than maintaining people on their safe and effective long term opioid therapy. This is the most recent of a great many studies which have repeatedly shown the same outcome. It is time for an immediate policy shift, forced tapers should never happen.
There are only two reasons to taper a patient off long term opioid therapy
- Patient choice and,
- If the patient is in imminent risk of harm e.g. has just experienced an overdose or other serious adverse event.
Otherwise, forced tapering opioids is much more likely to cause serious harms and should NOT be undertaken.
We have collected multiple recent large-scale studies that show that forced opioid tapering is associated with increased risk of mental health crisis, overdose and suicide.
