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Study: Opioid tapering in chronic pain patients is associated with increased overdose and mental health crisis extending for up to two years

opioid pain killers

https://www.sciencedaily.com/releases/2022/06/220613124547.htm

Date: June 13, 2022

Source: University of California – Davis Health

Researchers have found that tapering chronic pain patients off their opioid pain medications may be far more dangerous than continuing opioid therapy.   This runs counter to the current regulatory environment in Australia that assumes that all chronic pain patients benefit from reducing or stopping their opioid pain medications.

A new study by researchers at the UC Davis Center for Healthcare Policy has found that patients on stable doses who had their doses tapered by at least 15% had significantly higher rates of overdose and mental health crisis that extended up to two years since the initiation of the taper, compared to their pre-tapering period.   

This was a very large study, including 19,377 patients, and found a total of 21,515 tapering events. Those events included emergency department visits or inpatient admission for drug overdose, withdrawal or mental health crisis events such as depression and/or suicide attempts.  The study compared these events with the pre-taper period, and found a 57% increase in overdose and withdrawal incidents, and a 52% increase of in mental health crisis, including suicide attempts.

Patients included in the study were all on stable opioid doses of at least 50 morphine mg equivalent (MME) or higher for the previous year before tapering was initiated.

There are at least seven studies (references at bottom) that find similarly that opioid tapering leads to significant patient harms.  And yet Australian Deprescribing Guidelines are currently under review that recommend opioid tapering in all cases, even where the patient must be tapered involuntarily.  

This, and other, studies demand that this policy of force tapering patients be re-examined and abandoned.  For many patients, the evidence is clear that tapering causes far worse outcomes than maintaining opioid therapy.  

And what none of these studies are saying overtly is what every chronic pain patient on opioids knows:  Opioids are very effective for reducing pain and improving quality of life. Take those opioids away and the pain returns. The returning pain is severe.  Faced with a lifetime of intractable and untreated pain some patients will see suicide as the only way out of pain. 

This is a travesty.

It is unnecessary and it is NOT evidence-based medicine.

Since the changes around opioid regulations that came into effect in June 2020 in Australia, many GPs stopped prescribing opioids and forced tapered all their patients. How many of these patients have experienced adverse events? How many overdoses? How many suicides?  No one is counting. 

While some patients will benefit from opioid tapering, it is clear that most do not benefit. Most experience harms.  So how is the clinician to decide which patient will benefit?

Simple. Ask the patient.  If the patient is willing to initiate tapering, then tapering may be started. If the patient does not wish to taper, in the absence of imminent danger, the patient should be maintained on their stable dose.  The evidence clearly shows this is the safest approach. 

Too many times, in my role as a patient advocate, have I heard the same story:  The GP initiates a taper, if the patient objects, the GP forces the taper.  The GP promises that if the pain increases, the dose will be reinstated.  A month later when the patient complains of unmanaged pain and asks for their previous dose to be reinstated, the GP refuses, citing ‘government regulations’ that disallow opioid prescribing for chronic pain.   This is a bald-faced lie, told shamelessly so as the GP can escape responsibility and avoid an uncomfortable patient encounter.

Because that’s what matters most – the GP’s comfort!

This study is the latest in a long line of studies that show that patients’ experience harms when tapering opioids  See the references below, seven recent studies that demonstrate the increased risk of overdose and death related to opioid tapering.  So this study outcome is nothing new, but it is significant because it shows that risk of mental health crisis and overdose persists for up to two years.

Joshua Fenton, Professor and vice chair n the Department of Family and Community Medicine at UC Davis School of Medicine and lead author of the study said:

While patients may struggle during the early tapering period, we reasoned that many may stabilize with longer-term follow-up and have lower rates of overdose and mental health crisis once a lower opioid dose is achieved. Our findings suggest that, for most tapering patients, elevated risks of overdose and mental health crisis persist for up to two years after taper initiation.”

The results of this study were not what at all what the researchers expected, and this and other studies demand a rethink of the current policies of tapering patients to lower doses of opioids in all cases.  Clearly not all patients benefit, and some are caused significant harms.

And what about informed consent?  Is it not the foundation of ethical medical care that all risks and benefits of a procedure or course of treatment be explained prior to commencement?  Yet with opioid tapering patients are assured they will experience improvements in pain and function, though this is rarely the case.  Never are the risks explained.   If tapering is associated with a 52% increased risk of a mental health crisis, as this study clearly shows, is this not something that the patient must be informed of?

It’s time GPs stopped spinning fairy tales and read the evidence themselves. And stopped getting their medical information from the media headlines and “Dopesick”.

There is clearly a need for clinicians and patients to discuss the risks and benefits of a dose reduction and if a dose reduction is agreed upon, this must be patient led.  The harms of tapering opioids may outweigh the benefits, and this must be disclosed.  Tapered patients must have close follow-up, and significant psychosocial support, unlike the current situation where many patients are abandoned, and left with no healthcare at all.  This support must be long-term, as the risks of overdose and mental health crisis persist for up to two years.  GPs need to consider risks carefully and ensure they have the skills and resources to provide that support, or risk serious harms to their patient.  And take responsibility for those harms. 

And, to state the obvious, if a patient is not coping well on lower doses and experiencing increased pain, then the previous dose should be reinstated immediately and the taper abandoned.  If a patient is experiencing increased pain, lower quality of life and mental distress, then the safest path is to maintain long term opioid therapy.

“We hope this work will inform a more cautious approach to decisions around opioid dose tapering,” Fenton said. “While our results suggest that all tapering patients may benefit from monitoring and support up to two years after taper initiation, patients prescribed higher doses may benefit from more intensive support and monitoring, particularly for depression and suicidality.”

The idea that tapering opioids is beneficial in all cases has been proven to be false.  The current policy of tapering all patients off opioids must be reversed.  There is NO opioid crisis in Australia.     

Any policy based around tapering all patients to a certain threshold or to zero opioid is not supported by the evidence. The practice must cease and patients need to be able to trust that their GPs will manage their intractable pain in a compassionate and evidence-based way: with opioid pain medications where appropriate.   Forced tapers should never occur.

Pain management must return to evidence-based medicine., And the evidence shows that opioids are safe and effective. That addiction is rare in chronic pain patients as is overdose except where patients are tapered off their opioid medications.  And that tapering causes serious harms, including suicide.

Source data:

Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation

https://pubmed.ncbi.nlm.nih.gov/32131996/

Patient outcomes after opioid dose reduction among patients with chronic opioid therapy

https://journals.lww.com/pain/Abstract/2022/01000/Patient_outcomes_after_opioid_dose_reduction_among.10.aspx

Mortality After Discontinuation of Primary Care-Based Chronic Opioid Therapy for Pain: a Retrospective Cohort Study

https://pubmed.ncbi.nlm.nih.gov/31468341/

Opioid medication discontinuation and risk of adverse opioid-related health care events

https://pubmed.ncbi.nlm.nih.gov/31079950/

Association Between Opioid Dose Variability and Opioid Overdose Among Adults Prescribed Long-term Opioid Therapy

https://pubmed.ncbi.nlm.nih.gov/31002325/

Association of Dose Tapering With Overdose or Mental Health Crisis Among Patients Prescribed Long-term Opioids

https://jamanetwork.com/journals/jama/fullarticle/2782643

Association of Opioid Dose Reduction With Opioid Overdose and Opioid Use Disorder Among Patients Receiving High-Dose, Long-term Opioid Therapy in North Carolina

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2791566

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