International Stakeholder Community of Pain Experts and Leaders Call for an Urgent Action on Forced Opioid Tapering

https://academic.oup.com/painmedicine/article/20/3/429/5218985

We, the undersigned, stand as a unified community of stakeholders and key opinion leaders deeply concerned about forced opioid tapering in patients receiving long-term prescription opioid therapy for chronic pain. This is a large-scale humanitarian issue. Our specific concerns involve:

• rapid, forced opioid tapering among outpatients;
• mandated opioid tapers that require aggressive opioid dose reductions over a defined period, even when that period is an extended one.

Opioid tapering guidelines were created, in part, to decrease harm to patients resulting from high-dose opioid therapy for chronic pain. However, countless “legacy patients” with chronic pain who were progressively escalated to high opioid doses, often over many years, now face additional and very serious risks resulting from rapid tapering or related policies that mandate extreme dose reductions that are aggressive and unrealistic.

Rapid forced tapering can destabilize these patients, precipitating severe opioid withdrawal accompanied by worsening pain and profound loss of function. To escape the resultant suffering, some patients may seek relief from illicit (and inherently more dangerous) sources of opioids, whereas others may become acutely suicidal. Regardless of one’s view on the advisability of high-dose opioid therapy, every thoughtful clinician recognizes rapid tapering as a genuine threat to a large number of patients who are often medically complex and vulnerable. Indeed, even slower tapers should include realistic, patient-centered goals that are achievable and account for individual patient factors.

New and grave risks now exist because of forced opioid tapering: an alarming increase in reports of patient suffering and suicides within and outside of the Veterans Affairs Healthcare System in the United States.

Reports suggest that forced tapering is also occurring in patients on opioid doses below the Centers for Disease Control and Prevention Opioid Guideline threshold of 90 morphine equivalent daily dose. These patients too are at risk of harm from overly aggressive tapering.

Patients on legacy opioid prescriptions require different considerations and careful attention to the methods by which opioid tapers might be considered and implemented. Currently, no data exist to support forced, community-based opioid tapering to drastically low levels without exposing patients to potentially life-threatening harms. Existing data that support rapid reductions of opioid doses—often to zero—were conducted in highly structured, supportive, interdisciplinary, inpatient settings or “detox” programs in which medications and other approaches were used to minimize the symptoms of withdrawal. These data do not inform community-based opioid tapering. Currently, nonconsensual tapering policies are being enacted throughout the country without careful systems that attend to patient safety. The methods by which a taper is conducted matter greatly.

We therefore call for an urgent review of mandated opioid tapering policies for outpatients at every level of health care—including prescribing, pharmacy, and insurance policies—and across borders, to minimize the iatrogenic harm that ensues from aggressive opioid tapering policies and practices.

Almost 18 million Americans are currently taking long-term prescription opioids. We ask the Department of Health and Human Services to consider the following to mitigate harms in this special, at-risk population:

• Enact policies that prohibit or minimize rapid, forced opioid tapering in outpatients taking legacy opioid prescriptions (this includes prescribers and health care organizations, pharmacies, and insurance payors).
• Provide compassionate systems for opioid tapering, if indicated; that includes careful selection, patient-centered methods, close monitoring, triaging of adverse events, and realistic end-dose goals that are evidence-based and derived from applicable outpatient tapering data.
• Convene patient advisory boards at all levels of decision-making to ensure that patient-centered systems are developed and patient rights are protected within the context of pain care.
• Require inclusion of pain management specialists at every level of decision-making about future opioid policies and guidelines.

In standing as a unified community of concerned scientists, experts, citizens, and leaders of pain organizations in our respective countries, we call for the development and implementation of policies that are humane, compassionate, patient-centered, and evidence-based in order to minimize iatrogenic harms and protect patients taking long-term prescription opioids.

Filed under: General Problems