Jon Porter, MD, understands the complexity of the opioid-prescribing debate all too well.
Dr. Porter is medical director of University of Vermont Medical Center’s Comprehensive Pain Program, which includes alternative therapies to manage chronic pain. But he’s also a prescriber for dozens of long-term patients who continue to receive elevated doses of opioids.
The welfare of these patients is spurring new concerns for governmental regulators and providers like Dr. Porter. They worry that, amid a push to decrease opioid prescribing, many people are being cut off too quickly from medication that plays a crucial role in their lives.
Several recent studies underscore the risks of abruptly decreasing or stopping opioid prescriptions, including physical and psychological distress, illicit drug use and death. So federal officials and a growing number of physicians are calling for a more cautious approach that’s guided by enhanced collaboration with patients.
“We have an opportunity to really be thoughtful about how we work with folks,” Dr. Porter said.
Experts say widespread overprescribing was a fundamental fuel for the opioid epidemic. Federal officials draw a straight line from prescription-opioid overdoses to a “second wave” of deaths involving heroin, and from there to the current rash of overdoses involving fentanyl, a synthetic opioid often produced illicitly.
Over the past several years, a concerted effort by governmental officials and health care providers has drastically reduced the number of prescription opioids in circulation. Nationwide, officials have noted a 56.5 percent drop in high-dosage opioid prescriptions between 2006 and 2017, and Vermont officials report a 40 percent reduction in prescribed opioids since 2016.
Overall, the trend is positive, says Tim Lahey, MD, director of clinical ethics at UVM Medical Center.
However, “as with any intervention, reducing opioid doses comes with risks that we should not ignore,” said Dr. Lahey, who also is an infectious disease physician and a professor of medicine at University of Vermont Larner College of Medicine.
And there is growing evidence that some providers – who are under pressure, both real and perceived, to slash prescribing rates – are systematically cutting doses for long-term opioid patients without carefully considering the effects.
People are Suffering
“My concern generally is that the pendulum has swung,” said Dr. Porter, who is also an assistant professor of family medicine at UVM Larner College of Medicine. “Everybody’s afraid of being sanctioned in one form or another, and we’re not responding to what I think are the very legitimate needs of the folks who are suffering.”
That suffering may be widespread, and the consequences can be serious or even deadly, new studies show.
For example, a 2019 report examining chronic opioid therapy patients in the Bronx, New York, found that patients who had their opioids significantly tapered were four times more likely to terminate medical care.
Termination of care puts patients “at risk for opioid misuse and illicit opioid use, either because of poorly controlled pain or because of self-treatment of opioid withdrawal,” the study’s authors wrote.
Another study, which focused on chronic pain patients at a Seattle clinic, found that discontinuation of opioid therapy “did not reduce risk of death and was associated with increased risk of overdose death.”
While concerns about opioid use disorder may drive providers to make prescribing changes, “it may be misguided to discontinue opioids without careful identification and adequate treatment of this disorder,” the Seattle study’s authors wrote.
But a third study – this one involving Vermont patients – suggests that addiction treatment may not often be considered by prescribers when tapering opioids.
That study focused on Medicaid beneficiaries receiving “high daily doses” of opioids, and researchers found that the median length of time for stopping an opioid prescription was just one day. That means half of the patients in the study didn’t have their doses reduced at all before discontinuation.
Furthermore, although 60 percent of the study’s subjects had been diagnosed with substance use disorder before their prescriptions were tapered, less than 1 percent of them received a medication to treat that disorder.
The Vermont study’s authors looked for signs of “adverse events” among those whose prescriptions were stopped. They found plenty: 49 percent had an opioid-related hospitalization or emergency department visit.
Balancing Efficacy and Safety
Studies like these, along with the firsthand experiences of doctors and patients, have led to calls for more caution and deliberation when cutting back on opioid prescriptions.
In 2019, a nationwide group of providers – including Lahey – signed a letter calling on the federal Centers for Disease Control and Prevention to evaluate the impact of involuntary opioid tapers. The letter also demanded that the CDC “issue a bold clarification” of its 2016 opioid-prescribing guidelines.
Recently, the U.S. Department of Health and Human Services (HHS) took a step in that direction by releasing a guide for clinicians on “appropriate dose reduction or discontinuation” of long-term opioids.
The department’s message is clear: “Unless there are indications of a life-threatening issue, such as warning signs of impending overdose, HHS does not recommend abrupt opioid dose reduction or discontinuation.”
One of the department’s key recommendations is collaboration with patients, and basing prescribing decisions on “individual patient needs.”
Dr. Lahey agrees. “The best medicine requires us to adapt guideline-driven medicine to specific patient characteristics and goals of care,” he said. “Put another way, good listening can protect patients from any number of harms, including cookie-cutter approaches to protecting patients from the risks of opioid therapies.”
But even with new precautions in play, evaluating a patient’s opioid needs can be a complex process. Dr. Porter says conversations about tapering a long-term opioid prescription are stressful for both the patient and the clinician, and he says there’s a risk of “rupturing that therapeutic relationship.”
So he advocates a “nuanced approach that really is committed to being humane.” Adapting the Comprehensive Pain Program’s group-support sessions for use in primary care practices could be one potentially helpful change, Dr. Porter said.
Some patients are going to remain on high doses of opioids, Dr. Porter said. So he sums up the prescribing debate this way: “What’s the best balance we can strike between efficacy and safety?”
This story was reported by Mike Faher, with the University of Vermont Health Network.