Federal health officials on Thursday released a guide for clinicians who are considering tapering patients’ opioid prescriptions, highlighting the benefits of safe reductions in dosages while warning against abrupt drops for people who have been on the drugs for long periods.
The recommendations come amid concerns that some chronic pain patients’ dosages have been unsafely pulled back and that providers have sometimes abandoned patients. Some experts and advocates have warned that overly aggressive reductions or forced cutbacks have led some patients who are dependent on the drugs to seek out illicit sources of opioids or consider suicide.
The anxiety around prescribing built in response to the opioid crisis, which drove more than 47,000 fatal overdoses in 2017 alone. The crisis was caused in part by some clinicians overprescribing the drugs, leading to cases of addiction in patients and a source of pills that were diverted. Prescribing levels have dropped since 2012, and some advocates have warned that the fear around opioids has left some patients unable to get them.
The new guide marks the government’s attempt to strike a balance between reducing the amount of opioids prescribed and ensuring patients aren’t left behind. It also reflects concerns that prescribing guidelines released by the government in 2016 were misapplied and contributed to inappropriate tapers.
On a call with reporters Wednesday, Dr. Brett Giroir, an assistant secretary at the Department of Health and Human Services, said it was possible to address the roots of the addiction crisis while helping people receive the medications they need.
“It is a false choice to say we can only limit opioid use disorder, or addiction, or have pain control,” he said.
Overall, the guide casts the decision to taper as an individualized one that prescribers and patients should reach together. Tapers may need to go slowly and their effects should be reviewed throughout the process. Patients need to have their concerns addressed, the guide stresses. It even suggests clinicians reiterate to patients that, “I’ll stick by you through this,” and to offer other forms of support.
Successful tapers to lower dosages can lead to improvements in sleep, mood, and overall daily function without leading to a resurgence of pain, according to the guide. But it also describes the risks of rapid tapering on the first of its six pages. It warns that doing so can induce withdrawal symptoms and recommends that abrupt dose reductions only happen when there are concerns about impending overdoses or other life-threatening issues. It also provides examples of when patients and prescribers should consider tapering, including when the drugs appear not to be working for pain control, or when the patient has side effects or starts taking certain other types of medications, including benzodiazepines.
On the call with reporters, Dr. Deborah Dowell of the Centers for Disease Control and Prevention said there are not specific targets that dose reductions should try to hit. Instead, patients and clinicians should find doses where the benefits of opioid use outweigh the risks.
“Tapering success does not mean getting down to zero or to any particular dose,” Dowell said.
While experts widely agree that overprescribing contributed to the opioid addiction crisis, there’s been an ongoing debate about how insistently to pursue tapers for chronic pain patients. Many who have been on opioids for years have grown dependent on the drugs, and it can be difficult for them to come off the medications. It can also be hard to distinguish whether tapering is leading to a return of pain or temporary symptoms of withdrawal.
While some experts have preached caution — in some cases advocating leaving patients at high doses if tapering could throw off their lives — others argue that leaving patients on these doses for long periods is bad medicine. Higher dosages of opioids are associated with overdose risk, and there is evidence that chronic opioid use can leave people more sensitive to pain and contribute to anxiety and depression.
Much of the debate has focused on a set of 2016 prescribing recommendations from the CDC. The guidelines were a measured set of proposals, including that clinicians treating chronic pain try other therapies before opioids and prescribe only the lowest effective dose and duration of the drugs. The CDC suggested that prescribers “work with patients to taper opioid to lower dosages or to taper and discontinue opioids” in cases where the harms of taking the drugs outweigh the benefits.
But after the guidelines came out, insurers, pharmacies, states, and law enforcement agencies started cracking down on high prescribing, often pointing to the guidelines as the source of their policies. Clinicians grew even more nervous about treating chronic pain patients, advocates said, and sometimes dismissed their patients.
Earlier this year, the authors of the CDC guidelines wrote in a follow-up paper that their recommendations had been misapplied. They said that some agencies and companies used the guidelines incorrectly to justify an “inflexible application of recommended dosage and duration thresholds and policies that encourage hard limits and abrupt tapering of drugs dosages.”
Dowell (who is one of the authors of the CDC guidelines), Giroir, and Dr. Wilson Compton of the National Institute on Drug Abuse also wrote a piece in JAMA Thursday describing the tapering guide. In it, they write that “clinicians have a responsibility to provide care for or arrange for management of patients’ pain and should not abandon patients.”
They add: “For patients who are unable or unwilling to taper and who continue receiving high-dose or otherwise high-risk opioid regimens … close monitoring and mitigation of overdose risk are recommended.”
About the Author Reprints
My wife is a cancer survivor has been on narcotics for over 6 years. Last week she received a a letter from her pain management doc stating she’s no longer a patient in his practice. No tapering, no reason. Hasn’t my wife been trough enough ? No one seems to care. Anymore….
DEA nets over 17 kilos fentanyl in massive, multi-state bust
6-state surge, the federal Drug Enforcement Administration and local police departments made 645 arrests and seized $2.5 million in drugs within less than two weeks.
From Nov. 11 to 22, DEA agents and police made the arrests and seized 17.9 kilograms of the potentially deadly opioid fentanyl, 7,800 illicit fentanyl pills, 13.9 kilgrams of cocaine, 3.1 kilograms of heroin and 2.5 kilograms of methamphetamine from throughout New England, according to the DEA. They also seized 51 firearms and $1.2 million cash.
https://www.bostonherald.com/2019/12/10/dea-nets-over-17-kilos-fentanyl-in-massive-multi-state-bust/
7 tons of METH every 3 days. And pain patients are still the problem.
It is easier for me to use a proxy server and get drug on line. Pills cost to much, so I can get a oz of fentinal from China shipped to my door, easier than i can go to my pain management and get my script filled. The Shipper also garentee delivery or if the feds get it they will ship anougher free of charge to replace the one the feds got.This is crazy. You are creating monsters. Is this what you really want.
CDC, DEA NEED TO STAY OUT OF OUR DOCTORS OFFICES. THE REAL PROBLEM IS STREET DOPE, MIXED WITH PSYCHE DRUGS AND BOOZE. WHEN THE CDC DIRECTOR DOESN’T EVEN KNOW HIS OWN 37 YR OLD MUSICIAN SON IS A HEROIN ADDICT. SINCE WHEN DOES A VIROLOGIST A PAIN SPECIALIST ESPECIALLY 1 WHO FUDGES HIS OWN REPORTS TO THE CDC? I’ve lived in pain nearly 40 years, most days I suck it up. I’ve tried your crap drugs that are more addictive than that measly 7.5 mg NORCO I took 3 times a day. Tried your Cymbalta, most ended up with A Fib trips to the ER. Osteoarthritis drugs ruined my GI Tract. Now the Colon no longer functions on it’s own. And eliminating foods I can’t digest, has made me a Type 2 Diabetic. Because all that was left that did digest was pasta, bread, and soft meats. Oh, BTW no seeded food either. Diverticulosis can turn to Diverticulitis in a hurry.
Why are all these “Opioid Tapering Guidelines” suddenly coming out? So, Instead of doing the Correct thing to put a Stop once and for all to all this damn unnecessary Opioid hysteria, Insanity, Ignorance, and Forced Tapers that are happening…Instead, they have chosen to just put out “Tapering Guidelines” that are Clearly stating its OK to Force Taper Chronic Pain Patients but just make sure you do it “Slow” so that the harm to the patient is minimized? Really? These Tapering Guidelines being released all over are “Fully Condoning” Unnecessary Forced Tapers of ALL Patients regardless of the circumstances and these Tapering Guidelines will cause the same amount of harm IF NOT MORE HARM Than the Fatally Flawed 2016 CDC Guidelines did. They will be misinterpreted the same way…by Physicians, Hospitals, Insurance Co’s and Payors who will all refer to Tapering Guidelines stating All Patients must be tapered to extremely low arbitrary dose cutoffs per the 2019 Opioid Tapering Guidelines recently being released so all they did was Further perpetuate forced tapers causing grave harm to those who need these medications. This mess just keeps worsening at a rapid pace and all damn common sense is gone. Let me tell you something as a Chronic pain patient who has a debilitating progressive painful disease who has been successfully treated with High Dose Opioids around the clock everyday for 15 YEARS…My Body was accustom to the Dose that worked for me. I NEVER had any issues, problems or even side effects. My dose of Opioids gave me Quality of life and I remained at high functioning because of it. After 15 Years at a Stable dose There was essentially ZERO Yes, Zero Risk of me suddenly “Overdosing” and Dying from the dose My body was used to taking. That literally just does Not happen. You dont take the same dose everyday for 15 Years and just all of a sudden overdose and die. This is something that needs to be understood. When Overdoses do happen to those who have been on these medications for that long at a stable dose regardless of their daily MME it is ALWAYS due to Poly drug use. Meaning use of “Multiple medications combined, illegal drugs or Alcohol.” So to state that these medications are dangerous at any dose over 90 MME is FALSE. To state that Chronic Pain Patients are at risk of overdose and dying suddenly at doses over 90 MME again is Completely FALSE. Its damn time to state these facts as myself along with hundreds of thousands of other Chronic pain Patients Nationwide are being Force Tapered off of the medications they needed to live. I have been completely destabilized as my Dr. Is citing CDC Guidelines as the ONLY Reason he is force Tapering me down to an ineffective dose of 90 MME. I have lost all quality of life and functioning. I have become homebound staying in my pajamas all day and only leaving for my monthly Dr. Appt at which point my medications are cut another 10 mg. I can no longer attend my sons soccer games, go shopping, stand to make dinner at night or clean my home and this is all for what? So I can reach an extremely low arbitrary dose cutoff because the people making these laws dont understand that I will not suddenly drop dead from my medications at a dose far greater than 90 MME? So because of their Ignorance and utter stupidity I am made to suffer through hell as my own children watch my further decline daily wondering why mom cannot get up to do the things I used to do with them and for them everyday.? My life is Not worth living anymore. The pain is immense and the withdrawals are severe after being on these medications for 15 Years. I wouldn’t wish this life on my worst enemy. EVERYTHING has been taken from me because someone else decided my dose was unsafe. This is god damn criminal what is happening. I understand the Suicides. If it wasnt for my kids, I would become another statistic of pain related suicide due to forced tapering and lost quality of life. I’m too young to live in this pain and there is No cure for my disease. My medications were SAFE FOR MY BODY. I’m not a damn idiot, never used drugs, I dont drink alcohol and I took my medications as prescribed always. Yet, They are being taken from me at a rapid rate. With each cut I further losing more functioning. Is this worth it? Hell No. For What? It’s all happening for literally nothing. The Ignorance, Opioid Hysteria, utter stupidity is shocking. And the Force tapers are now being “Justified” as Tapering Guidelines are being released. Doesn’t matter how slow you go. If the patient is losing quality of life and functioning to reach an arbitrary dose cutoff…Than what the hell is it being done to them for?
My heart goes out to you &I feel your pain &totally relate. After prescribing it to me for 10 years my Dr arbitrarily discontinued my Tramadol &took me down from 300 to 200 mg from November to Dec &over the course of 6 weeks totally has me off Tramadol (I have a little bit left) It is criminal what is happening. I reported him to the State medical board &contacted a malpractice Attorney
The PROP addiction Specialists who wrote those Guidelines should be held fully & severely accountable for every death, every Suicide and every person currently suffering immensely today for there actions in writing a death sentence for Intractable Pain Patients. They are also in violation of the UN POW TORTURE statues. Intractable pain is 1 disease or 1 car accident away. Chronic pain does NOT last forever. Intractable pain last for a LIFETIME. New Survey Data Confirm That Opioid Deaths Do Not Correlate With Pain Pill Abuse or Addiction Rates – Reason.com https://reason.com/2019/08/21/new-survey-data-confirm-that-opioid-deaths-do-not-correlate-with-pain-pill-abuse-or-addiction-rates/?fbclid=IwAR2u04BqR124rb10rJPpt1RnU0SCfjq2Rn7EEh04rNxTDLZ7umD5LdijGEo
SUICIDES associated with forced tapering of opiate pain treatments
https://medium.com/@ThomasKlineMD/opioidcrisis-pain-related-suicides-associated-with-forced-tapers-c68c79ecf84d
Major Fentanyl Shipment from China Seized in Mexico (25 tons) https://www.breitbart.com/border/2019/08/25/25-tons-of-fentanyl-from-china-seized-in-mexico/
My pain mgmt Dr. an anesthesiologist who owns his own pain mgmt practice In Portland, OR who I have been under the care of for 10 Years abruptly decided in June of 2019 to begin an Force Taper of my Opioid medications down to meet CDC Guidelines arbitrary random dose threshold of 90 MME. I was stable on my medications at the same dose for 10 years. It worked well to control my pain. I never ever had any problems or adverse side effects. Since this force taper has began I have been completely de-stablized and thrown into a never ending cycle of complete hell between pain and withdrawal that wont end. My Dr. Does not care and wont budge from the forced taper plan. I have no want to even get out of bed anymore. I cannot sleep as I cant hold still, my anxiety is so bad I break down in tears every hour. I cannot eat. I cannot function. All of this for what? Because someone else doesn’t agree with the medications I take or the dose? My god. When I stop and think about WHY I’m going through this hell I get extremely angry. I did nothing wrong, I followed the rules, I took my medications exactly as prescribed. I had UAs, Pill counts etc…So why is it that I’m being punished and forced down to an arbitrary dose threshold that is way, way to low for my body so low that its completely ineffective leaving me suffering tremendously ? I fully understand why Chronic pain Patients are committing Suicide. Anything is better than living like this. If it wasn’t for my kids I would have ended it already. I cant live this way and I have absolutely no desire to continueto do so. This is hell. Its unbelievable to me the pain, suffering, deaths, suicides that are being caused by completely unnecessary, unwarranted Forced Opioid Tapers to an arbitrary dose cutoff and yet No one has done a damn thing to stop it or rescind the fatally flawed CDC Guidelines that caused all this outright outrageous Opioid hysteria. The PROP addiction Specialists who wrote those Guidelines should be held fully & severely accountable for every death, every Suicide and every person currently suffering immensley today for there actions in writing a death sentence for Chronic Pain Patients. I would be more than happy to sign a waiver releasing my Dr. From any and all liability for Opioid doses over the arbitrary limit 90 MME if it meant My medications would be given back along with my life that was previously stable. As adults we should have an option to choose especially when it comes to our healthcare. I was Stable and well at a dose I had been at for 10 Years that was 100% SAFE for my body with No adverse side effects. Now? My life is upside down. I can no longer function. Is this worth it? Destroying someone’s life to force them down to a random arbitrary number that caused the medications to be ineffective thus leaving that person suffering? My god. This hell. It’s all for absolutely nothing.
My TERRIFIED doctor PCP is to SCARED to write even 2 days worth. Neurologist takes care of my Valium for Neuropathy, Pain Seizures, and Gastropresis spasms. I’ve been told it’s illegal. Neurologist said BS. I can have 1 script for 30 days at 20 mg and 5 refills. I’ve been on this same dose so long, and it works 95% of the time. Unscientific Guidelines Are Being Peddled As ‘Evidence-Based’ Medicine https://medium.com/the-compendia-project/unscientific-guidelines-are-being-peddled-as-evidence-based-medicine-97ce32aeb830
Ever since the Faux Opioid Crisis began I’ve been saying the goal is NO Pain Meds. Note the language change. Both Illicit and Legal are now Opioids, I’m old enough to remember when Pain Meds were called Pain Meds. Illicit drugs Street drugs that Junkies used to get High on, not to control any pain. Chronic meant short term of a few weeks because of a broken bone or surgery needing rehab. That Pain that was level 10 that lasted over a few weeks was a Sub Set of Chronic and was called INTRACTABLE PAIN, TREATED ONLY WITH A NARCOTIC PAIN MED. NO ONE REMEMBERS THESE TERMS. Don’t bother to ask for an alternative these Scared doctors don’t want to prescribe the side effect riddled crap for fear of Patient Lawsuits. Generic Neurontin sent me to the ER with A Fib. MY SCARED PCP WON’T SCRIPT A PAIN PILL. EVEN WITH A 2 IN FOLDER OF DISEASE, DEGENERATION, NEUROPATHY, 14 OF THE 15 DRUGS FAILED AND CAUSED BAD SIDE EFFECTS. GASTROPARESIS, AND THE TYPICAL PAIN OF BEING 71. How the Feds Impede Evidence-Based Opioid Treatments | Cato Institute https://www.cato.org/multimedia/cato-daily-podcast/how-feds-impede-evidence-based-opioid-treatments?&utm_source=facebook&utm_medium=social-media&utm_campaign=addtoany&fbclid=IwAR0soz_1MYVTDHtkg5Ix0i1wrpybKF0zmgKxDrxJOdFyUVRcbNGTIh4tn5w
HHS Issues Guide to Reducing Long-term Opioid Use Without Harming Patients in Chronic Pain
https://www.ajmc.com/focus-of-the-week/hhs-issues-guide-to-reducing-longterm-opioid-use-without-harming-patients-in-chronic-pain?fbclid=IwAR2HBVa8eYw7M15nCI_1FbWZ-VBwMJpFBiFthreO3w7n6EhYLrDr20SxuGY
Border Patrol seizes enough Fentanyl to kill people in 5 states https://www.cbp.gov/newsroom/local-media-release/border-patrol-seizes-deadly-combination-narcotics?fbclid=IwAR2oZTReOxukjJ5Oi4GjuS-R2vV4ZfBJMhsUR6ufoOn9pNoBaAU_huP1oX0
3 men –47 bags of Fenatayl
https://13wham.com/news/local/deputies-3-men-arrested-in-byron-with-47-bags-of-fentanyl
https://www.channel3000.com/news/crime/madison-man-sentenced-to-four-years-for-distributing-heroin-laced-with-fentanyl/1131292734
According to a release, he distributed heroine laced with fentanyl or cocaine to an undercover officer five times in March and April 2019. Officers served a search warrant at his home in April and recovered 1.7 grams of heroin and a handgun in the garage. He pleaded guilty on July 15.
During the transactions, Lacey-Robinson was on state probation after being convicted of distributing heroin in 2014. His state of probation was revoked in June 2019 and he was sentenced to 18 months in prison.
YOU ARE EXPENDABLE. WHICH IS WHY STATES ARE PASSING EUTHANASIA LAWS, BUT WON’T USE THE SAME DRUGS ON DEATH ROW INMATES BECAUSE THEY ARE CRUEL AND INHUMANE.
I have degenerative disc disease, arthritis, canal stenosis, neuropathy, radiculopathy. My spine has been fused at L4-L5& S1, nerve decompression surgery was also done as well as laminectomy on L4-L5 right side. 1st, 2nd. & 3rd metatarsals (mid foot arthritis) were fused however my body rejected the titanium implant used on the 1st metatarsal. While waiting for the bones to fuse I experienced excruciating nerve pain. I had 3 plates and 12 screws that needed to be removed.
I live with excruciating pain 24/7 and have been put on 5mgs vicodin 3 to 4 times a day. Over the last year the pain in my back and hips has been getting worse. I explained this to my GP of 18 years and was met with we are tapering you off of the pain medication as it does not seem to be helping. I asked what it would be replaced with and was told “nothing”. We are taking you off pain medication completely. My Dr. then stated that she just wanted to treat people with colds etc… and if I wanted I could find another doctor. Well colour me shocked!!!! Also because I had asked for something different to help with the pain she noted this in my records as “continues to ask for more pain medicine” . I have been so upset about this that I can’t sleep and cry all the time. I saw a pain mgmt Dr. Friday and was told that my type of pain can’t be treated with opioids, WHAT THE HECK DOES THAT MEAN? I have been abandoned and left to live in hell all thanks to the CDC.
Opioids work best for most chronic pains, unless in rare instances, a person may be intolerant of them. We know that, and they need to know that. It appears that the Trump admin. & HHS have finally got the facts about this issue from the right people, and positive changes are taking place. You should not be denied, nor have to live in pain like this.