Thursday, October 3, 2019

Part 2 - We Were Wrong 20 Years Ago, Our Current Response to the Opioid Crisis is Wrong, But We Should Still Be Helping Most of our Long-Term Patients Reduce Their Opioid Doses

by Drew Rosielle (@drosielle)

This is the second in a series of several posts about many aspects of my current thinking about opioids.

The first post is here: Part 1 – Introduction, General Disclaimers, Hand-Wringing, and a Hand-Crafted Graph.

Over-prescribing fueled the current drug overdose epidemic, and many of us who thought we were stamping out needless suffering contributed to the epidemic.

A lot of what I read and believed about opioids early on in my career was wrong.

I’m old enough to remember those heady days in which there was a pretty large and ‘successful’ movement in American medicine to greatly liberalize opioid use for all sorts of pain syndromes...pain as the 5th vital sign, discussions of there being a tort for undertreating pain, etc. In my own way, I was part of the movement, although I was trained at the beginning of the end of the movement.

There was a utopian feeling in the air at the time: pain is a terrible scourge, it’s under-diagnosed and under-treated, it’s this huge cause of all this disability and needless suffering, and liberalizing the availability of opioids would be a key intervention to transform all these suffering people’s lives for the better.

We were wrong.

Opioid prescribing and availability did increase markedly, but population levels of pain and disability didn’t improve. Most people’s lives were not transformed for the better, and at least some were ruined via iatrogenic opioid use disorder. How many were ruined due to increased opioid prescribing for chronic pain is really tough to know. But undoubtedly there was a marked increase in community exposure to prescription opioids (obtained both legally and illegally) from 2000-2010 which was key in fueling the current drug overdose epidemic, and increased prescribing was an important enabler of all this.

And while I very much believe that, I still observe that we actually have very little helpful data about nearly anything to do with this topic, despite the fact that everyone (including me) has strong opinions about it.

Even questions like 'How many patients with chronic noncancer pain who are prescribed opioids also have an opioid use disorder?' has no clear answer (let alone the associated-but-different question of ‘How many patients with chronic noncancer pain who are prescribed opioids acquire an opioid use disorder from those opioids?’). Estimates are from 3-40%, but the data are heterogeneous and difficult to interpret, which is a polite way of saying the data are a total mess. Eg, most studies are single institution studies, some studies have rigorous definitions of OUD, some which look at ‘aberrancy’ which is not an adequate proxy of opioid use disorder, some studies clearly involve a chronic pain population, some which look at anyone who has received an opioid prescriptions which is not the same thing as a chronic pain population – the data are a total, flaming, mess. See, eg, J Med Toxicol 2012 PMC: 3550262, or Subst Abuse Treat Prev Policy 2017 PMID: 28810899).

There are better population-level data on rates of overdoses in patients who are prescribed opioids as outpatients. The big story there is that while risk of overdose does increase more or less linearly with the amount and duration of opioid prescribing, the absolute risk goes from – on a population level – miniscule to tiny as prescription opioid ‘exposure’ goes up. In one of the better studies on this, which looked at state-wide North Carolina data, the risk of fatal overdose was 0.022% per year for all comers (anyone who received an opioid prescription). For those in the highest tier of prescription opioid exposure, the rate of fatal opioid dose remained tiny: 80 per 10,000 person-years (Pain Med 2016 doi:10.1111/pme.12907). That’s still too many, but I think it helps give nuance to the apparent Extreme Urgency some policy makers and insurers are putting on patients/prescribers to rapidly push a whole bunch of people off of chronic opioid therapy. You get a sense that some policy makers think We Must Do This Or They All Will Die. This is totally, demonstrably, false.

It’s illuminating, for instance, to look at Krebs JAMA 2018. This was a 12 month practical randomized controlled trial of opioids in a narrow patient population – osteoarthritis – showing that opioids generally weren’t effective and had opioid side effects. A lot could be said about Krebs 2018, but it was at least a reasonably lengthy study period, and helpfully showed that opioids weren’t generally effective for osteoarthritis in this population over a pretty long time. Although, importantly, the study excluded patients who had received any opioids, so all these patients may have been pre-selected to not do well with/want opioids anyway. Regardless, and relevant to the larger discussion of the opioid crisis, it also importantly showed that while the patients receiving opioids had common opioid side effects, they did not acquire opioid use disorders, nor die at a higher rate than the non-opioid users. So while Krebs 2018 has been used very loudly by some to prove opioids are ineffective for ‘chronic pain’, it’s often missed that it could just as easily be used to emphasize that prescribing opioids carefully to risk-screened patients then monitoring them closely over the long-term is actually quite safe and in fact not a driver of the opioid overdose crisis.

All this being said, opioid prescribing in the US went up massively in the 1990s and 2000s, and I myself don’t have any doubt that lead to broadening the population-level exposure to opioids and fueled the current crisis. All of us who prescribed are implicated in that in some way.




As much as I believe the above to be true, opioid prescribing has been falling since ~2010, as drug overdose deaths have continued to sky-rocket due to a resurgence of heroin and now illegally manufactured fentanyl analogues. And current policies which have essentially forced (encouraged? forcibly encouraged?) clinicians to taper patients off opioids despite many of those patients demonstrating long-term safety with chronic opioid therapy is barbaric, harmful, & shameful, and I’m proud of the efforts of many in our field and organized medicine to push back against it. See for instance Chad Kollas’ (@ChadDKollas, see also his Pallimed posts here and here) and others’ work at AAHPM, the AMA and elsewhere, and the coalition who put together this open letter. Read the letter if you haven’t, it’s clear headed and right about everything, and I’m glad that there are at least signs the CDC is listening, which is not to say that the semi-literate insurance representatives who cannot read a prescription indication line which says: “chronic neoplasm related pain” and who refuse to allow my terminal cancer patients refills without hours of wasted work, are listening…yet.

And, just to wallow in my anger about all this a bit, it’s become really crystal clear to me that there’s a large group of people out there who are enforcing a version of the CDC guidelines that just don’t exist. (In case you’re not familiar with the guidelines: 1) they are aimed at primary care clinicians not pain specialists, and they can be quite easily summarized as saying 2) chronic opioid therapy, particularly high-dose opioid therapy, for chronic noncancer pain should be used rarely, as a last resort, and only undertaken with clear informed consent of the patient and with close attention to the safety of the patient.) Like pain doctors telling their patients who they’ve maintained on chronic opioids for years that the CDC says they can’t do it anymore and have to taper them (I hear this all the time). Or a pain doctor at a peer review of a specialist physician accused of overprescribing stating that the CDC guidelines state that opioids can’t be used for chronic pain (100% true story, I was part of that peer review). Or state policies and insurance plan policies making it nearly impossible to prescribe moderate to high doses, even in circumstances where a patient has demonstrated long-term safety and stability, etc.

But…

While I think forced tapering of stable/thriving patients “because CDC” is wrong and harmful, I’ve found myself in the past 5 – 10 years accepting that many patients on chronic opioid therapy for ‘chronic non-cancer pain’ and even long-term cancer pain, can be tapered and have a better quality of life off opioids, or on lower doses. Some won’t and we can’t tell in advance all the time who will benefit from opioid tapering or not, and it’s really important that those patients whose lives worsen with opioid tapering are cared for by knowledgeable clinicians who can manage their pain including continuing chronic opioid therapy.

All that’s true, but I continue to be impressed with the number of patients who do great with opioid tapering – it’s a lot of effort and, literally, pain on their part, but many feel better afterwards, have a better quality of life, and honestly I would never have believed that 10 years ago and it’s taken me seeing it over and over again to believe it. It’s really changed my views on opioids, and I continue to believe we really don’t know a lot about what opioids do, how they work, how they affect our patients’ perceptions and emotions.

It’s important to be really clear why I think many of these patients should be helped through a tapering process: it’s not because most of them have substance use disorders, it’s not because they are using opioids dangerously or contributing to the larger opioid crisis (these patients are some of the most highly scrutinized patients in all of medicine), it’s not because their risk of overdose is large (there is a risk, but it’s small), but it’s because opioids are not improving their quality of life, and are often worsening it, and they will feel better and be happier off of them. It’s been so eye opening watching many of my patients go through this – talking about how they can feel their emotions again (and all the messiness of that, but they are grateful they have their emotions back), about how reducing opioid doses was painful but after several months they find themselves being more active, they still have pain but it’s manageable, etc. It took me a while to come around to this, but I’ve now seen so many patients whose lives have been markedly improved coming off opioids, that I routinely work with my patients with longer prognoses to reduce their opioid doses, and it goes pretty well most of the time, and like most hard lessons in medicine, I learned it from my patients.

Read the rest of this series:

Part 1 – Introduction, General Disclaimers, Hand-Wringing, and a Hand-Crafted Graph.
Part 2 – We Were Wrong 20 years Ago, Our Current Response to the Opioid Crisis is Wrong, But We Should Still Be Helping Most of our Long-Term Patients Reduce Their Opioid Doses
Part 3 – Opioids Have Ceiling Effects, High-Doses are Rarely Therapeutic, and Another Hand-Crafted Graph

For more Pallimed posts about opioids.
For more Pallimed posts by Dr Rosielle click here.

Drew Rosielle, MD is a palliative care physician at the University of Minnesota Health in Minnesota. He founded Pallimed in 2005. You can occasionally find him on Twitter at @drosielle.

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