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.

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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.

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“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.”

  • Refreshingly powerful advocacy by “K”. Every action has a reaction and as is typical an “over reaction” has taken over and desperately needed patient care is being denied. Case in point for 6 months I sought treatment for “excruciating,” absolutely unbearable pain. Turned away. Meanwhile my spinal abscess was went untreated. My pain determined to be a ruse so could obtain “opiates.” When I arrived at ER my Xanax was reduced significantly and I was asked to “demonstrate” my inability to walk! Ok, got up and fell to floor. Urine leaking on legs. Pulled up painfully by arms and vigourasly pushed halfway on to ER bed with med person having to lay on top of me so wouldn’t fall off. What ensued thereafter was emergency MRI detecting abscess. Immediate surgical removal followed by complete paralysis from waist down. Six months in hospital followed by second surgery on back to stabilize spine. My paraplesis condition and nightmare preceding cannot be rationally understood nor can the inhumane “assumptions” made throughout ordeal. Cruelty is an understatement. Bottom line for me is to fight for yourself. Doc’s have abandoned patients and the creed now: Do harm if faced with possible liability or loss of license. What tragic confusion has resulted unnecessarily. In putting forth “guidelines” we have created innumerable interpretations with primary goal not of patient care but of doctor care. Liability or loss of license has eclipsed true need of patients to receive appropriate care and worse yet the abandonment of appropriate care altogether.

  • Simply put, my life has been DESTROYED by the draconian 2016 CDC Guidelines. My doctor of 8+ years decided out of the blue to retire. I looked for months trying to replace him. I wasn’t able to and was forced to go to a pain clinic that immediately told me that were going to taper me, whether I agreed to it or not, down to zero. One year ago I was able to hike daily. Not long after my forced taper, I was housebound. One month later, I was bed bound, where I’ve been for the past 3 to 4 months. They told me their goal was to improve my functionality. Clearly they lied, because they aren’t adjusting their (it’s not mine) treatment program with full knowledge of my current quality of life. Did I mention they
    put me on 3000 mg/day acetaminophen with 6 refills, the most deadly drug on the planet, especially when taken long term. That, plus the 3 other drugs they had me on, made me seriously suicidal. “Are you sure, because for me to try the next option, we have to exhaust this option first.” Am I sure? How goddamn condescending can you be? My treatment is being guided by my horrible health insurance, so still no adjustment to my pain medication. I could easily be on a single pain medication and be allowed to get back to my life. Nope. They have me on a total of 5 right now. Please tell me about how they are supposed to weigh the risks, because their treatment plan has literally endangered my life. If it wasn’t for my family, I would have ended it last month, but I could never do that to them. What’s worse though, them witnessing the complete destruction of my life every day month after month, or just allowing me to go peacefully?
    I have residual trauma from a horrible accident that shattered and deformed my right foot along with my left ankle needing 3 pins screwed into my lower leg. You can see the trauma, I’m not lying about the pain, but here I am stuck in bed.
    “Do no harm” my ass.

    • Well I had a mother that had severe severe back pain for pretty much my whole life nobody could even touch her back and the doctors 20 years later Sayo she’s addicted to pain meds what the hell do you expect when you got a lady on pain meds for 20 years and anyways I’ve had back problems myself I’ve had back surgery but I think I might know something that might help all of you that suffer with pain here’s the thing don’t knock it till you try it because you got at least try it first second about guarantee you that this will help all of you to an extent unless you’re looking to just get high but I believe in Suboxone there’s different kinds I think I’m not sure I don’t know a whole lot about it but I do know that it works for pain and if that don’t work there’s methadone and here’s the thing it’s legal doctors prescribe it Medicaid pays for it so all you ladies are men out there that are having problems getting any opiates in our suffering from pain try it I’m telling you what it’s good it’s better than nothing I’ll tell you that right now

  • In the late 70’s or early 80’s, I read a study about chronic back pain that totally changed my view on the subject. I kept the paper for years, eventually loaning it out, never to see it again. Time has altered my recollections. I recall that study was done at a Texas health science center. The study group was adult men, out of work, at least one, with chronic back pain. All had the complete services of the medical center. Randomly, half were given a personal trainer and a membership in an athletic club. They were followed for 3 years. After 3 years 89% of the men with personal trainers had successfully returned to work. They had half the back surgeries and one quarter of the doctor visits as the controls. None of the controls successfully returned to work. They spent an average of $9,000 per person in the exercise group, $90,000 in today’s terms. Do you know this study? Do you how I could find it today? I have been searching for it ever since the internet became a thing.
    Ray

    • exercise is the goddess’ gift to us. i adore long, 4- or 6-mile walks a decade post stroke since my partner is an accomplished wildlifr photographer.

    • For some suicide becomes only way to eradicate the intense, unrelenting pain in the absence of pain relief.

  • I am a physical therapist who has had severe pelvic pain for a year. The most opiate medication I’ve been on to get some relief is 3 Percocets a day, now cut back to 2 lowest dose hydrocodone. After trying numerous nerve blocks and nonopiate pain medications (one which caused seizures and another respiratory depression), back exercises in PT, chiropractic, massage, accupunture, etc., I was told by the nurse practitioner at my pain clinic that I had to have a nerve ablation to my back (which is unrelated to the cause of my pain) or the pain clinic would cut off my hydrocodone. I felt this was unprofessional, manipulative, and harmful so I sought a second opinion. I was told there that my problem is pelvic floor dysfunction and pudental neuritis. The ablation would not only be painful but ineffective. There is something very wrong with a system that uses a patient’s pain and helplessness to force them into unwanted and harmful procedures by threatening them with retaliation for non-compliance. This present political climate has also stigmatized patients with medical conditions causing unending pain as drug seekers looking for a high
    and has created adversarial relationships between doctor and patient. Those doctor’s who prescribe opiates ethically and responsibly are being threatened with license removal. People in pain are becoming more handicapped and despairing. Believe me. I’ve been there and still am

  • I know it happened to me too. Now I’m afraid to have any kind of procedure. I was left with alot of pain and no one cared..they were scared because none of them wants to loose thier license or even be put in jail. It looks like a witch hunt to me.

  • I can’t take OTC meds for pain, even if they worked which they don’t. No one asked or looked at my medical records to see the Stage 3 kidney disease, the Enlarged Heart with Mitral Valve leak, the Degenerative bones, or the ruined GI tract. Doesn’t leave a whole lot of options available to a 71 yr old. Where are all the Geriatric doctors we need? Internist want healthier patients and are 10 min visits. Have 1 size fits all blood draw equipment that doesn’t work for fragile or small veins. Why do I need so many blood draws you scar my arms? My ENDO could do all the blood work and send you the results. Limiting the blood work done.

  • The opioid epidemic so to say for patients that has been taking higher doses for many years now doctors are scared to write a script for cronic pain patients. I am one of them. There is no certain does for patients

  • I have a progressive neurological disease that’s been killing me for 18 years. I had a life expectancy of only three years when I got sick. The pain that goes with the advancement of my disease has been treated by a legitimate pain management doctor for 17 years. I use a combination of non narcotics, injections into joints of medication, and a fentanyl patch. I have always used it properly. Have not had highs and lows that come with oral doses or the higher addiction levels that come with oral doses. Everyone agrees this is the best treatment for my situation. It doesn’t relieve my pain it just brings it to a tolerable level. The problem came when I had an emergency surgery and the surgeon didn’t want to give me acutely the doses of medication I needed because I had such a high tolerance. He was afraid of backlash that he would get even though it was the right care for me while I was in the hospital.

    • I know it happened to me too. Now I’m afraid to have any kind of procedure. I was left with alot of pain and no one cared..they were scared because none of them wants to loose thier license or even be put in jail. It looks like a witch hunt to me.

  • I dont think you all understand how bad the pain is unless you have a pain that never goes away i understand people abuse the drugs just makes it a lot harder on the people that dont abuse the system ive needed an increase in my med but afraid to talk to them afraid they will keep me from getting better my quality of life is bad i wouldnt be able to walk with out my meds im sorry im just vented or letting u know some of us need our meds

    • Ask them to increase it. If you have a good report with your Dr. who knows your medical history.

      Some places will over prescribed but stay away from those. They over prescribe not caring.

    • Hi Barbara, you are so true with saying stay away from those Drs that don’t give a shit I’ve been in pain management for many years (12+) and have been on some of the strongest meds there are the strongest med was opanas I took myself off of them which was very hard!! After I did that they tried cutting my oxycodone down which didn’t work. But you know the longer your on one medicine your body gets immuned to it. And you ask yourself what now. Good luck with your Dr and medicine. Cindy

    • I receive 120-240mg of oxycodone daily. The doctors are out there. We’re working on tapering, but at my request, through my desire. Nothing forced. I know the frustration of finding a doctor. But keep trying. Read reviews. Don’t give up.

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