WaPo: Opioid Crackdown Forces Chronic Pain Patients Off Meds

[drusso]

https://beta.washingtonpost.com/health/opioid-crackdown-forces-pain-patients-to-taper-off-drugs-they-say-they-need/2019/09/10/3920f220-c8da-11e9-a4f3-c081a126de70_story.html?fbclid=IwAR3JRUBkVb5Arcc0YomrjBrmVmJ_FwSr8-mlz1bE3vt02joHJBuN_PuAl3U

"The United States is now in the midst of a “national experiment” as misguided as the one it conducted 20 years ago, when doctors put millions of patients on opioids with little understanding of the consequences, says Tami Mark, senior director of behavioral health financing and quality measurement for RTI International, a North Carolina think tank. She has conducted one of the few formal studies of “forced tapering” of opioid patients.“This national effort at ‘de-prescribing’ is again being undertaken with limited research on how best to taper people off opioid medications,” Mark says. “You can’t just cut off the spigot of a highly addictive medication that rewires your brain in complex ways and not anticipate negative public health consequences.”

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[Ducttape]

Ballantyne, the pain specialist, is now a professor of anesthesiology and pain medicine at the University of Washington and also president of Physicians for Responsible Opioid Prescribing. She is among the most influential leaders of the movement to cut down the country’s dependency on opioids. The United States still is the world leader in the reliance on opioids.

But even she says that “the pendulum did swing too rapidly.” Some patients who have been taking high doses of opioids for a long time may be better off sticking to what’s worked for them, she said. The most important change in medical practice — one adopted by Veterans Affairs— is to cut down on “new starts,” the patients taking opioids for the first time for ailments that might not require that kind of painkiller.


last paragraph:

And there’s another shadow hanging over their home: Hank’s great-nephew overdosed on heroin, possibly laced with illicit fentanyl, earlier this year, they say. His name was Kevin Samuel Crathern. He was 26. The Skinners say the young man’s parents decided to scatter his ashes along his favorite trail in Yosemite National Park

 

[drusso]

Ballantyne, the pain specialist, is now a professor of anesthesiology and pain medicine at the University of Washington and also president of Physicians for Responsible Opioid Prescribing. She is among the most influential leaders of the movement to cut down the country’s dependency on opioids. The United States still is the world leader in the reliance on opioids.

But even she says that “the pendulum did swing too rapidly.” Some patients who have been taking high doses of opioids for a long time may be better off sticking to what’s worked for them, she said. The most important change in medical practice — one adopted by Veterans Affairs— is to cut down on “new starts,” the patients taking opioids for the first time for ailments that might not require that kind of painkiller.


last paragraph:

And there’s another shadow hanging over their home: Hank’s great-nephew overdosed on heroin, possibly laced with illicit fentanyl, earlier this year, they say. His name was Kevin Samuel Crathern. He was 26. The Skinners say the young man’s parents decided to scatter his ashes along his favorite trail in Yosemite National Park

If you were a plaintiff or defendent expert on a Negligent Taper case, how would you rely on this study?


J Subst Abuse Treat. 2019 Aug;103:58-63. doi: 10.1016/j.jsat.2019.05.001. Epub 2019 May 5.
Opioid medication discontinuation and risk of adverse opioid-related health care events.
Mark TL1, Parish W2.
Author information
1RTI International, United States of America. Electronic address: [email protected].2RTI International, United States of America.
Abstract
BACKGROUND:
Between 2012 and 2017, the United States dramatically reduced opioid prescribing rates. While this may be appropriate given the opioid epidemic, there has been little research to guide the clinical practice of discontinuing patients from opioid medications and opioid death rates have continued to increase.
OBJECTIVE:
To determine the relationship between time to opioid discontinuation and the risk of an opioid-related emergency department visit or hospitalization among high dose opioid users.
DESIGN:
We applied Cox proportional hazard models to 2013-2017 Medicaid claims data to research this relationship.
PARTICIPANTS:
Medicaid beneficiaries in Vermont who filled prescription opioids at high daily doses (at least 120 morphine milligram equivalents) for 90 or more consecutive days and who subsequently discontinued opioid prescriptions (n = 494).
MAIN MEASURES:
The outcome was an opioid-related adverse event defined as an emergency department visit or hospitalization with a primary or secondary diagnosis of opioid poisoning or substance use disorder.
KEY RESULTS:
The median length of time to discontinuation was 1 day indicating that half of patients had no dose reduction prior to discontinuation. 86% of patients discontinued within 21 days (considered rapid tapering in recent clinical guidelines). 49% of members had an opioid-related hospitalization or emergency department visit. After controlling for sociodemographic and clinical factors, each additional week of discontinuation time was associated with a 7% reduction in the probability of having opioid related adverse event (p < 0.01). Although 60% of members had a diagnosed substance use disorder prior to tapering, <1% of beneficiaries were transitioned onto an opioid use disorder medication.
CONCLUSIONS:
Faster rates of opioid tapering were associated with a greater probability of adverse events and many patients discontinued opioids suddenly, with no dose reduction. Additional clinical guidance, research, and interventions are needed to ensure that patients' opioid prescriptions are discontinued safely.
Copyright © 2019 Elsevier Inc. All rights reserved.

 

[Ducttape]

no. the study is flawed. all these patients had opioid poisoning or substance use disorder diagnosis. that is not a diagnosis to give someone being tapered off opioid medications. it begs the following information:

1. how many of those individuals stopped after 1 day were stopped because of current illicit drug use?
2. legally, they shouldn't be tapered, but stopped immediately and referred to opioid use disorder treatment. PCPs do not usually prescribe opioid use disorder medication (ie suboxone).
3. 49% had opioid related side effects... 60% had opioid use disorder. do you taper/continue to prescribe for an addict substance use disorder patient? it appears that there is a percentage of people who had opioid use disorder that did not have side effects.


from my personal experience, those patients that I stop opioids immediately because of a positive UDS are more likely to go to the ER - to get their next fix.

 

[drusso]

no. the study is flawed. all these patients had opioid poisoning or substance use disorder diagnosis. that is not a diagnosis to give someone being tapered off opioid medications. it begs the following information:

1. how many of those individuals stopped after 1 day were stopped because of current illicit drug use?
2. legally, they shouldn't be tapered, but stopped immediately and referred to opioid use disorder treatment. PCPs do not usually prescribe opioid use disorder medication (ie suboxone).
3. 49% had opioid related side effects... 60% had opioid use disorder. do you taper/continue to prescribe for an addict substance use disorder patient? it appears that there is a percentage of people who had opioid use disorder that did not have side effects.


from my personal experience, those patients that I stop opioids immediately because of a positive UDS are more likely to go to the ER - to get their next fix.

I don’t follow you. How do you recognize a Negligent Taper when you see it?

 

[SeniorWrangler]

The journalist is really hyping a study made on claims data that can’t possibly be a study of forced tapers.

 

[Ducttape]

I don’t follow you. How do you recognize a Negligent Taper when you see it?

you would have to look at each individual taper.

don't tell me that you slowly taper someone off of their opioids who test positive for cocaine, heroin, or amphetamines.

 

[lobelsteve]

I don’t follow you. How do you recognize a Negligent Taper when you see it?

Negligent taper would be >50% reduction per day while noting no aberrant behaviors leading to taper. If patient has OUD, abusing, misusing, or taking not as prescribed, no taper is warranted. Risk of killing with next Rx outweighs discomfort of taper. They can kill themselves with an overdose of drugs they bought off the street or with my Rx. I prefer to leave my Rx out of the equation and try and get them to detox- the only safe thing that can be done. The complete failure of mental health and insurance to allow this to occur is the real issue.

 

[drusso]

Negligent taper would be >50% reduction per day while noting no aberrant behaviors leading to taper. If patient has OUD, abusing, misusing, or taking not as prescribed, no taper is warranted. Risk of killing with next Rx outweighs discomfort of taper. They can kill themselves with an overdose of drugs they bought off the street or with my Rx. I prefer to leave my Rx out of the equation and try and get them to detox- the only safe thing that can be done. The complete failure of mental health and insurance to allow this to occur is the real issue.

Variability in dose might also be a marker for neglient taper...

JAMA Netw Open. 2019 Apr 5;2(4):e192613. doi: 10.1001/jamanetworkopen.2019.2613.
Association Between Opioid Dose Variability and Opioid Overdose Among Adults Prescribed Long-term Opioid Therapy.
Glanz JM1,2, Binswanger IA1,3,4, Shetterly SM1, Narwaney KJ1, Xu S1,5.
Author information
1Institute for Health Research, Kaiser Permanente Colorado, Aurora.2Department of Epidemiology, Colorado School of Public Health, Aurora.3Colorado Permanente Medical Group, Aurora.4Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora.5Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora.
Abstract
IMPORTANCE:
Attempts to discontinue opioid therapy to reduce the risk of overdose and adhere to prescribing guidelines may lead patients to be exposed to variability in opioid dosing. Such dose variability may increase the risk of opioid overdose even if therapy discontinuation is associated with a reduction in risk.
OBJECTIVE:
To examine the association between opioid dose variability and opioid overdose.
DESIGN, SETTING, AND PARTICIPANTS:
A nested case-control study was conducted in a large Colorado integrated health plan and delivery system from January 1, 2006, through June 30, 2018. Cohort members were individuals prescribed long-term opioid therapy.
EXPOSURES:
Dose variability was defined as the SD of the milligrams of morphine equivalents across each patient's follow-up and categorized based on the quintile distribution of the SD in the cohort (0-5.3, 5.4-9.1, 9.2-14.6, 14.7-27.2, and >27.2 mg of morphine equivalents).
MAIN OUTCOMES AND MEASURES:
Opioid overdose cases were identified using International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes. Each case patient with overdose was matched to up to 20 control patients using risk set sampling. Conditional logistic regression models were used to generate matched odds ratios and 95% CIs, adjusted for age, sex, race/ethnicity, drug or alcohol use disorder, tobacco use, benzodiazepine dispensings, medical comorbidities, mental health disorder, opioid dose, and opioid formulation.
RESULTS:
In a cohort of 14 898 patients (mean [SD] age, 56.3 [16.0] years; 8988 [60.3%] female) prescribed long-term opioid therapy, 228 case patients with incident opioid overdose were matched to 3547 control patients. The mean (SD) duration of opioid therapy was 36.7 (33.7) months in case patients and 33.0 (30.9) months in control patients. High-dose variability (SD >27.2 mg of morphine equivalents) was associated with a significantly increased risk of overdose compared with low-dose variability (matched odds ratio, 3.32; 95% CI, 1.63-6.77) independent of opioid dose.
CONCLUSIONS AND RELEVANCE:
Variability in opioid dose may be a risk factor for opioid overdose, suggesting that practitioners should seek to minimize dose variability when managing long-term opioid therapy.
PMID: 31002325 PMCID: PMC6481879 DOI: 10.1001/jamanetworkopen.2019.2613

 

[Ferrismonk]

Variability in dose might also be a marker for neglient taper...

JAMA Netw Open. 2019 Apr 5;2(4):e192613. doi: 10.1001/jamanetworkopen.2019.2613.
Association Between Opioid Dose Variability and Opioid Overdose Among Adults Prescribed Long-term Opioid Therapy.
Glanz JM1,2, Binswanger IA1,3,4, Shetterly SM1, Narwaney KJ1, Xu S1,5.
Author information
1Institute for Health Research, Kaiser Permanente Colorado, Aurora.2Department of Epidemiology, Colorado School of Public Health, Aurora.3Colorado Permanente Medical Group, Aurora.4Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora.5Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora.
Abstract
IMPORTANCE:
Attempts to discontinue opioid therapy to reduce the risk of overdose and adhere to prescribing guidelines may lead patients to be exposed to variability in opioid dosing. Such dose variability may increase the risk of opioid overdose even if therapy discontinuation is associated with a reduction in risk.
OBJECTIVE:
To examine the association between opioid dose variability and opioid overdose.
DESIGN, SETTING, AND PARTICIPANTS:
A nested case-control study was conducted in a large Colorado integrated health plan and delivery system from January 1, 2006, through June 30, 2018. Cohort members were individuals prescribed long-term opioid therapy.
EXPOSURES:
Dose variability was defined as the SD of the milligrams of morphine equivalents across each patient's follow-up and categorized based on the quintile distribution of the SD in the cohort (0-5.3, 5.4-9.1, 9.2-14.6, 14.7-27.2, and >27.2 mg of morphine equivalents).
MAIN OUTCOMES AND MEASURES:
Opioid overdose cases were identified using International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes. Each case patient with overdose was matched to up to 20 control patients using risk set sampling. Conditional logistic regression models were used to generate matched odds ratios and 95% CIs, adjusted for age, sex, race/ethnicity, drug or alcohol use disorder, tobacco use, benzodiazepine dispensings, medical comorbidities, mental health disorder, opioid dose, and opioid formulation.
RESULTS:
In a cohort of 14 898 patients (mean [SD] age, 56.3 [16.0] years; 8988 [60.3%] female) prescribed long-term opioid therapy, 228 case patients with incident opioid overdose were matched to 3547 control patients. The mean (SD) duration of opioid therapy was 36.7 (33.7) months in case patients and 33.0 (30.9) months in control patients. High-dose variability (SD >27.2 mg of morphine equivalents) was associated with a significantly increased risk of overdose compared with low-dose variability (matched odds ratio, 3.32; 95% CI, 1.63-6.77) independent of opioid dose.
CONCLUSIONS AND RELEVANCE:
Variability in opioid dose may be a risk factor for opioid overdose, suggesting that practitioners should seek to minimize dose variability when managing long-term opioid therapy.
PMID: 31002325 PMCID: PMC6481879 DOI: 10.1001/jamanetworkopen.2019.2613

A Ph.D (doesn't write opiates), a research internist (doesn't write opiates), and a master's degree biostatistician (doesn't write opiates). I'm sick of people who don't write opiate trying to tell me it's okay to write high dose opiates.

 

[Ducttape]

um... not sure if that is a good marker for negligent taper. that article essentially states that patients with high variability of dose are more likely to overdose.

patients going to ER for symptoms of withdrawal are not the same population as patients who are presenting with overdose.

if anything, the population that is more likely to overdose, shouldn't they be more likely to be rapidly tapered?


and lobelsteve, I would add the caveat that there is a limit to your "negligent taper is >50% reduction per day". someone on 12 mcg/fentanyl is not going to go to 6, likewise with butrans 5, and probably not for MED<20, or everyone at that final step to off is negligently being tapered. yes I'm nitpicking

 

[lobelsteve]

um... not sure if that is a good marker for negligent taper. that article essentially states that patients with high variability of dose are more likely to overdose.

patients going to ER for symptoms of withdrawal are not the same population as patients who are presenting with overdose.

if anything, the population that is more likely to overdose, shouldn't they be more likely to be rapidly tapered?


and lobelsteve, I would add the caveat that there is a limit to your "negligent taper is >50% reduction per day". someone on 12 mcg/fentanyl is not going to go to 6, likewise with butrans 5, and probably not for MED<20, or everyone at that final step to off is negligently being tapered. yes I'm nitpicking

No taper from 12fent or 5 butrans needed anyways.