Harm reduction and the chronic pain patient

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I thought I understood the core tenets of harm reduction and strongly support them but I was “educated” on Twitter a bit ago about HR in setting of chronic pain. The CPPs and some HR providers feel it is inappropriate to have these patients to taper off/down on opiate doses or switch to MAT. HR principles support maintaining these patients on large doses of opiates because they are stable on them These are obviously the most vocal patients/advocates and they are the exception to the statistical conclusion. They referenced a new NEJM paper showing tapers result on suicide and other negative outcomes.

Maybe my thinking is dated but AFAIK opiates for chronic pain are not supported especially for things like EDS and Fibro, and it’s reckless to allow them to continue on large doses opiates despite a lack of clinical support.

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[deleted875186]

I don’t think the harm reduction arguement makes sense. Patient is suicidal or will overdose on illicit drugs if you slowly taper off medications, so you must continue for eternity? Even though the high dose opioid regimen is not supported by anyone, has high risks of adverse effects and overdose itself? Plus the reason person may be suicidal anyway is the dependence on the opioid in the first place? Nobody will ever make this argument cogent. We are not taking about harm reduction in the same way it’s typically used to defend suboxone or supplying clean needles etc.

 

[deleted875186]

As people on this forum have suggested, if anyone was serious about this harm reduction idea, they would set up an opioid dispensary similar to a methadone for these people. High dose opioids are not appropriate for outpatient monthly visits with a pain clinic.

 

[Baron Samedi]

If someone is on high dose opioids its because opioids were ineffective at treating their pain and improving their function. If someone fails to improve at a reasonable MED, they're not going to magically do so at an unreasonable MED.

 

[kstarm]

There is some evidence that tapering people leads to increase morbidity and mortality during the taper. That needs to weighed against the risks of continuing the current regimen, and how much benefit it is providing. For high dose opioid regimens, my opinion is the risk of continuing is almost always greater than the risk of rotation to bupe or slow tapering in an environment that can address the issues that typically come up as people taper.

 

[Ducttape]

these Legacy patients are in a conundrum between the risks of continued opioid use vs tapering or cessation to a lower more sustainable and safer dose. clearly, shared decision making and tapering with shared goals is most appropriate and most likely to be successful. forced tapers wont work - unless there are extenuating circumstances (abuse, addiction, diversion). this does require a lot of "handholding" to help the patient get through the withdrawal portion.


for most patients, the issues come to a head when the prescriber decides to retire or leave an area.

imo, the best solution would be to require physicians who are prescribing inordinate amounts - say, over the 150 MED level so there is clearly intent - to be tied to prescribing until they die. no retiring. prescribe until his/her death, or prison.

 

[Centurion38]

The problem with these high dose legacy patients is many (?almost all) have undiagnosed OUD or misuse/diversion. You find this out when you try to taper them. Oxycodone is worth $2 per mg on the street right now.

With Medicaid patients this is especially true. That's why I don't take on patients for tapering unless I think I can be successful. I am a physician, not a DEA agent. Too often we are asked or expected by PCP's, Orthopedics et al to address a legal problem (misuse/diversion) with a medical treatment (opioid dose tapering).

 

[SeniorWrangler]

The other question is, does it protect you as a provider to say “I’m doing harm reduction”?
An SUD treatment provider prescribing methadone to prevent relapse on heroin can point to a strong evidence base and body of law.
What can a pain doctor prescribing high dose oxycodone point to?

 

[deleted875186]

The other question is, does it protect you as a provider to say “I’m doing harm reduction”?
An SUD treatment provider prescribing methadone to prevent relapse on heroin can point to a strong evidence base and body of law.
What can a pain doctor prescribing high dose oxycodone point to?

Absolutely.

I don’t think the DSM gives a definition of substance abuse that is helpful for identifying pain patients with opioid issues. There is so much misuse and diversion, it’s not worth the hassle of taking a legacy patient. Every single high dose one I’ve seen has funny business if I decide tj take them.