Correspondence: Opioid Tapering & Discontinuation
Tapering & Discontinuation: The Debate Lingers
The following comment was shared with PPM in response to the Fall 2019 HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics. The full version is available.
Despite considerable improvement over the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain, the new HHS guide is still substantially misdirected. The new guide appears to “double down” on previous errors and hazards of the 2016 recommendations, even after the CDC and FDA tried to correct widespread misapplication last spring through safety communications. In my opinion, the new guide fails to address 5 central issues.
Trials Data: Sean Mackey, MD, and several past presidents of the American Academy of Pain Medicine have asserted to the Governor of Oregon in a public letter that no body of data exists to establish positive benefits from mandated tapers of prescription opioid pain relievers in any patient cohort. Thus, why are opioid tapers continuing to be recommended?
Risks and Benefits: There is no validated profiling instrument for accurately predicting the “risks and benefits” of opioid therapy in individual patients. Treatment decisions in individuals are not the same as studies conducted among general populations which identify and correlate factors with risks.
MMEs: Why has HHS ignored the fundamental repudiation by the American Medical Association of morphine milligram equivalents (MMEs) as a measure of risk for establishment of best practices in pain management? AMA House of Delegates Resolution 235 (November 2018), resolved not only that ‘some patients with acute or chronic pain can benefit from taking opioid pain medications at doses greater than generally recommended in the CDC Guideline’ and that ‘no entity should use MME thresholds as anything more than guidance, and physicians should not be subject to professional discipline ... solely for prescribing opioids at a quantitative level above theme thresholds found in the CDC Guideline.’
Mortality Rates: Data show that there is no consistent cause and effect relationship between opioid prescribing rates and the overdose-related mortality rates. Twenty years of published CDC data reveal a strongly inverted demographic relationship between prescribing and mortality. Seniors over age 62 are prescribed opioids for pain about six times more often than youth under age 19. Yet, overdose-related mortality in youth is six times higher than in seniors. The work of Dasgupta, et al, (Pain Med, 2016) is also pertinent as the largest demographic and epidemiological analysis published to date on overdose.
Patient Behavior vs Underlying Disease Dynamics: There is no validated metric (other than physician experience) to distinguish between “drug-seeking behavior” and underlying disease progression or effects of under-treatment of pain. Lacking such a metric, physicians may be presented with a profoundly unethical choice between protecting themselves from censure and risking further compromises to the health of patients whom they may put into opioid taper programs.
Overall, it is time to recognize that while rapid tapering or abrupt discontinuation of patients maintained on opioid therapy is “a” problem; it is not “the” problem. Rather than a cosmetic “raising of the bridge,” in more careful tapering programs, US healthcare approaches need a lowering of the river of patient desertion, and outright withdrawal of the 2016 CDC guideline.
– Richard A. Lawhern, PhD, Patient Advocate
See also: Duensing’s discussion of how the HHS and CDC recommendations align and Reid’s review of guidelines for opioids in older adults.
Stem Cells for Myopathy?
Dear PPM,
I am a huge fan of the journal and find the information so helpful and hopeful for all the chronic pain patients that I treat. I was wondering if any PPM advisors have knowledge of stem cell treatments helping patients with myopathy from statin reactions. I have a patient who was given a statin many years ago and developed a disabling myopathy (rhabdomyolysis) that resulted in severe disability and poor quality of life. I think stem cells are her only hope.
– Anne Ingard, PT
Dear Ms. Ingard,
IV stem cells may be an option along with targeted stem cell therapy. However, there is no guarantee and this patient may require multiple treatments with an unknown number of cells. The bottom line is that this may cost anywhere from a few thousand to tens of thousands. If done correctly, the side effects are low, outside of a thinner wallet. That said, there may be other beneficial treatment options outside of stem cells, such as interventional approaches. In general, these myopathies are very hard to treat because they result in actual tissue damage that sometimes is irreversible. I hope this helps.
– Jay Joshi, MD, DABA-PM, FABA-PM
More on regenerative medicine for pain from Dr. Joshi and from Dr. Alderman.
