The Dangerous Game of Forced Opioid Reduction
By Forest Tennant, MD, Guest Columnist
A colleague who I highly respect just informed me of a woman with intractable angina who had multiple, inserted coronary splints and required a high daily dose of morphine. Without warning, her insurance company arbitrarily decided she did not need opioids. As one might expect, the forced cessation of opioids led to her death.
The forced reduction and/or cessation of daily opioids in stabilized patients have, in some corners of our country, reached the point of unscientific and inhumane hysteria. The craze to fight opioid abuse and force opioid dosages below 100 to 120 mg of morphine equivalents a day (MEQ) is now harming some patients who have been doing quite well on stable, daily opioid dosages. Some of the rhetoric and tactics being used to force opioid reduction are farcical if they weren’t so tragic in their consequences.
First, who is doing the forcing? There are multiple culprits: insurance companies, state legislators, regulators, and suppliers. Some of the tactics to force opioid reduction are indirect, such as limiting the amount of opioids a pharmacy can stock. Others are blatant, such as states that require physicians to seek a pain consultation if they continue to prescribe over a threshold MEQ level, even to patients who have been well maintained for a considerable time period. For example, in Washington State, a 120 mg/d MEQ threshold will trigger the prescribing physician to conduct, or refer the patient for, a pain consultation (exceptions and exemptions do exist). As noted by Stephen J. Ziegler, PhD, JD, “in some states, these thresholds appear in regulations, making the actions required actions, while in other states the thresholds appear in guidelines, making the actions merely recommended.”
Insurance companies are currently the most dangerous “forcers.” Neither patient, pharmacist, nor physician is prepared when a stable, opioid-maintained patient goes to fill a long-standing opioid prescription only to be told their insurance company has suddenly decided the patient should immediately cut their opioid daily dose by 30% to 70%, or even stop it altogether. The saddest aspect of this dangerous practice is that the motive is clearly greed, although the reduction may be accompanied by an “out-of-the-blue” statement that the forced reduction is for the patient’s safety. For example, insurance companies have recently informed long-standing, opioid-maintained patients that they have suddenly and capriciously decided they will no longer cover brand name opioids, injections, patches, compounded formulations, or a daily dosage above a specific level.
Insurance companies and some state guidelines are spitting out two illogical excuses for the forced reduction of opioids. One is that opioids dosages above 120 mg or so of MEQ are unsafe. Show me a study that indicates tissue toxicity of opioids at dosages over 120 mg in patients who have been maintained at a stable dosage for over 1 year. Patients who have been titrated up to dosages above 120 mg of morphine and periodically monitored by competent physicians almost always experience improved health and function, not the reverse. I have several patients who have been safely maintained on high opioid dosages and led quality lives for over 20 years!! Why force these folks into sickness, suffering, and possibly death by suddenly and capriciously claiming their life-saving medication is dangerous?
The other straw-dog is “hyperalgesia.” Would someone please tell me how I’m to define and diagnose hyperalgesia in a patient who has been well maintained on a stable opioid dosage—high or low—for over a year? Hyperalgesia has become a label and excuse to force down opioid dosages. Reputable and credible pain practitioners are not even sure it exists in a human who is well maintained on opioids. Whenever I see a patient who is on opioids and claims their opioids aren’t working as well as they used to, I take a hormone profile. Once I replace any deficient hormones, the patients’ opioids resume working.
My demand is for someone to send me the consensus document that tells me how to objectively diagnose hyperalgesia in patients who have been well maintained on opioids over 90 days. What’s more, if hyperalgesia exists, what harm does it do? If we really believe that hyperalgesia is a problem with high-dose opioids, we must remove all intrathecal opioid pumps because these devices deliver a MEQ directly to the CNS receptors that is far in excess of any dosage we can achieve by peripheral administration!!
Readers of Practical Pain Management well know that severe, constant pain has far more risks than any stable, daily opioid dosage. Severe pain adversely affects the cardiovascular, endocrine, immune, and neurologic systems. It sends patients to bed in agony to lead a short, suffering life. There is no need to take these risks in a caring, concerned society, as a minute extract from the opium plant can prevent these complications and the pathetic, miserable death that a forced opioid reduction can bring.
So what do we do at this point? First, physician’s need to correct any false comments about the imagined dangers of stable, on-going opioid dosages. Whenever possible, pain practitioners should attempt to prescribe non-opioid pharmaceuticals that have come forward in recent years. In the latter category, I place ketamine, anti-epileptic agents (gabapentin, pregabalin, etc), and neurohormones (oxytocin, human chorionic gonadotropin, and progesterone). I’ve cut my patients’ opioid use by about 50% over the past 5 years by use of these new agents. I also recommend obtaining an opioid serum level in patients who take over 100 mg of MEQ. The presence of a reasonable opioid serum level indicates that the patient is ingesting opioids and is functioning well with a high opioid dosage.
Lastly, and most important, families of patients who must take a high daily opioid dosage need to become publicly active as advocates for their loved one. Unfortunately, but realistically, patients who must take a high opioid dosage always have a debilitating condition such as arachnoiditis, CRPS, traumatic brain injury, post-encephalitis headache, or facial neuropathy, and are too ill to fend for themselves. But their family can. Its time families demand the right of their suffering loved ones to obtain opioids, and their direct and blunt communication should go to State Medical Boards, insurance companies, wholesale suppliers, and their elected representatives.
Also, pain patients and family members should start joining the emerging nationwide organizations that are now forming to fight back. While we physicians have little public voice left, families of pain patients can, should, and will be heard.
Dr. Forest Tennant is pain management specialist in West Covina, California who has treated chronic pain patients for over 40 years. He has authored over 300 scientific articles and books, and is Editor Emeritus of Practical Pain Management.
This column is republished with permission from Practical Pain Management.
The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.
Filed under: General Problems
I’m 35, I’ve been a pain patient since age 12. I’ve been a compliant and agreeable patient my entire life. In Dec the state of WA put an emergency suspension of my pain doctor’s license. That left me with 2 days of medication. Due to the climate of fear, my primary care can only prescribe 60MED a day morphine equivalent per their corporate policy which was why I was in specialty pain care in the first place. I had been for the last 5 years on a combination of oxycodone & fetanyl upwards of 480MED. The immediate impact of cutting my medication down from 480-60 almost killed me, after 36 days of the 60/day I got into a pain doctor, in that time my epilepsy became uncontrollable, my afib as well. I’ve been unable to leave my bed for 4 months. I’m now finally under the care of a pain doctor who’s entire goal is to get me to 120MED as it is the highest my state will allow, I went from 480-60-150 in 4 months. For me that’s not enough to get me even out of bed. This has destroyed my life. Prior to my doctor’s license suspension which by the way was arbitrary, no overdoses no diversion the suspension was solely based on amount prescribed per patient, he was a double specialty a pain doctor and psychiatrist, he was the specialist for the worst off most complex patients in our state and he was called an immediate threat immediate suspension no hearing still after 4 months no plan for his patients. But I digress, prior to the loss of my pain doctor I was able to care for myself, attend a swimming class for the disabled biweekly, I was doing OK for a severely-ill woman. Now I’m bedridden I’ve lost of much of my hair as this has triggered my autoimmune alopecia, lost 45lbs in 4 months, my epilepsy is now in intractable, I’ve developed worsening heart problems including worsening high blood pressure, I’m so weak in so much pain it’s scarring me. I’ve never been this weak scared or had this much sustained pain even with 20 years of surgeries and disease. I’m afraid for myself my family and every pain patient in our country. This is inhuman what’s been done to me. At 35 my life is over and I can’t figure out what I did to deserve this.
What do you do when a pain management facility basically tells you they are going to lower your dosage if you don’t try a spinal stimulator.
The patient is absolutely terrified of trying. the thought of something going wrong with the device and the possibility of infection or increased pain, After trying the tense unit that did not work but subsequently increased the pain aggravating the nerves and increasing her anxiety,
My Wife has chronic back pain. She is in pain management, I have gone to almost all of her doctors visits because they treat patients like drug seekers and its sickening. She went in and had L4 and L5 Fused 8 years ago and there is nerve damage from the surgery,
They just told her today in a round about way, that if she doesn’t try a nerve stimulator they will need to lower her meds. How can they do this. She is just about making it through the day with her current prescription, as it is ; that’s a very limited day at that.
I am so sick of seeing her go through this I know there are probably millions of people in the same situation and there has to be a better way.
Any input would be greatly appreciated.
What is someone in this situation supposed to due between the doctors being dictated to by the DEA on how to medicate patients?
Jeff.
Jeff, it seems as though your wife is living my life. It makes me want to ask who her pain specialist is….my husband and I both had the spinal stimulator stuffed down our throats. My father had one and had it removed because it caused more pain and trouble than it was worth (he is 82 now, has had it out for about 2 years, had it in about 7 years) I know of others that had it and when they wanted it out they had difficulties finding a surgeon to take it out, also insurance doesn’t like to pay for it to be taken out. Also you need to know that when they put the trial one in it is not done in the same manner as the permanent one and works better than the permanent one. As far as her surgery, I have had the same one, only I had a lower fusion also and arthritis removed from my spine at the same time. Did they tell you that once you have a fusion that the area above and below the fusion will also go bad? Didn’t tell me….oh the things I’ve learned since then… I also tried the tens unit, it felt like they had it directly connected to my brain! Bzz, bzz, bzz…and that was on the lowest possible setting..
My suggestions, if you want them is to try heat and a cream found at Walmart called blue emu for starters. I wish you and your wife all the luck, we know what it is like to be treated like criminals just trying to get out of chronic pain!
I have been active all my life wrestling over seas and around the country working in construction and wild land fire fighting being a scuba diver and avid outdoors man until I broke my back in several places then I spent years fighting in fighting the pain and silently suffering unwilling to go to the dr for pain meds. Now I live in pain I barely leave the house and suicide seems like I good alternative to what I go through daily. Each morning I have to fight the desire to stop the pain by drastic means. But the pain drives me to the edge and I want to jump off. I have lost everything my sweet heart my job my life I am a pariah and outcast. I do not leave my home and I am attacked by everyone because I am not the man they knew. The insurance (ohp) will stop coverage of long term pain meds this coming summer so I am reducing my pain meds and I was not on a high enough dose to be very effective as it was. I just hate the idea of being a slave to a drug so I take the min I can and try to get by until I cannot anymore. But the pain meds mean the difference between getting out of bed or not between suicide or not. I have lost everything and before the pain meds I tried drinking till the pain went away and being drunk all the time cost too much and was ineffective. Typing this makes my hands go numb. Idk what I will do advocates for marijuana say use that but I do not want to get high and I do not have the mo way to get the stuff that fights pain and does not get you high. Besides can it really compare to the level of pain reducing that opioids do? I hate that people know I am on pain meds that my life is in shambles that I lost my sweet heart because my life is in the gutter and she just could not take it anymore I am alone fighting the pain and now I will be forced off pain meds in a few months reducing them now is making me want to take the leap what will I do when I am off all together.
J. g., I feel your pain so much, both my husband and myself were completely shut off from our pain meds (after 10 years) with no notice and lucky we made it through withdraws! It has been just over a year for us now…quality of life is almost nonexistent, but the whole suicide is not an option, ever! Please remember that no matter how bad it gets, there are people out there who love you (even if they don’t understand your pain, most people who don’t live it doesn’t understand it or the other things it causes, depression, anxiety, sleeplessness, etc.) And committing suicide is like making them suffer instead of yourself. I don’t mean to sound heartless. I do know exactly how you are feeling, I was hit in a small car while sitting at a stop light, by a SUV going 40 mph at the age of 42, was told that my back was the same as a 80 year old (that was before I was hit) I have been disabled ever since. My husband was in an auto accident when he was 25 and should not have lived through it, he was life flighted, a coma for 30 some days, 19 hrs of facial surgery, crushed pelvis, broken hip, punctured lung, amongst many others… Basically everything but his arms. He was working again within 2 years with no pain meds ( or any other, only alcohol which almost ruined a marriage at 15 years, now married 25 years and very happy) for 10 years…,now we are just trying to make sure the pain doesn’t take us back to where we use to be! Guess what I am trying to say is hang in there, you truly are not alone! Please!
And this is why some clients turn to heroin….
Sending applauds your way for speaking up. I am so fearful of people making decisions about what works for me when they know nothing about my history or the condition I am in. I moved to a new state and without any concern, was completely stripped of a medicine that had been working well and one I had been on for 5 years. This past year has been a complete nightmare of 70/30 out of control pain and I’m so praying that 2016 holds hope. I had a Rheumatologist tell me last year that the only way I would be able to function in the slightest is living on pain medicines the rest of my life. Luckily I was sent to a great Pain Clinic who really believed in me and never took my self worth away. That worth was stripped to the core this past year and I can’t imagine being pushed further to the ground. I pray there is an ounce of compassion for me in the future and that is shared among others that are going through this scrutiny.
New Years wish..this article by Dr. Tennant would be published in all the newspapers, be a featured segment on 60 minutes, NPR, in TIme magazine, etc!
Really how can this get out into the media to counter all the propaganda out there?
Truth be told Dr. Tennant is saving lives. He saved my son’s life after he was abandoned by so called pain specialist who told him he’d just have to learn to live with the pain…almost died 6 weeks later ..from pain that had centralized and caused pituitary/ adrenal failure. So yes, I know people are dying from these policies.
Thank you Dr. Tennent. You are the onlyperson /doctor who is giving me hope that there are doctors that do care. I wish I lived out by you, im way across the country. .my brother and myself are both chronic intractable pain sufferers and have been put thru hell. My brother got talked into having his third back surgery two weeks ago. He is in agony. Surgeon is off enjoying the holidayseason in FL, while his patient, my brother, is in so much pain. He has been leaking fluid/blood from a hole where one of the incisions is for two weeks now. He has yet to give my brother something for pain, he gave him valium.He needs pain medication, doesnt want to be a walking zombie. I am so disgusted over this NEGLECT! And to think of the thousands upon thousands of legitimate chronic pain sufferers who too are being denied life saving medications makes me sick. !
I have been on 600 mg per day for over 10 years for intractable pain and my new doctor of over 5 years lowered me to 400mg per day and up to 90 mg of for breakthrough pain. If I went any lower I would be jumping off a bridge(seriously) as it is now on my “forced” lower dose I wake up with enormous pain all through the night. Im tired of the politicians and the greedy bastards who think they are helping in some strange and distorted way!If they want to help STOP ALCOHOL and CIGARETTE SALES that would do more good truly than their stupidity. It really looks like very soon all pain patients are gonna see el chapo and screw walgreens. I really hate that but I am no idiot I know what it takes to survive. Im not gonna let some DEA assh… or some pharmacist who does not have any idea about my medical condition dictate what I should ingest. These pharmacist really do think they are doctors,I could laugh they are just glorified pill counters and soon robots will put them out of business.I truly look forward to that! Anyway Im so sick and tired of each day reading some new great Idea to HELP ME!.I have been on the same dose for years. Its proven to work and Ive tried all the politically correct stuff and its just that nothing else! LEAVE ME ALONE this is between my doctor and me. No one else.
AGREED!!!!!