Forced tapering may harm patients with chronic pain on opioids
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LAS VEGAS — Patients enduring chronic pain may also encounter a stigma linked to their opioid treatment, and forced tapering exacerbates that burden, a presenter said at PAINWeek 2022.
We live in an environment of increased opioid pharmacovigilance, according to Kevin L. Zacharoff, MD, FACIP, FACPE, FAAP, a clinical instructor and course director for pain and addiction, and Distinguished Visiting Scholar in Medical Humanities, Compassionate Care and Bioethics at Renaissance School of Medicine at Stony Brook University.
“Regulatory agencies were looking for fewer opioids to be prescribed to save lives,” he said. Measures included restricting the number of pills prescribed and the length of time, tapering and ceiling doses, a move away from opioid-centric pain treatment.
Adverse effects of this include pain, stigma, bias and ethical dilemmas, Zacharoff said.
“If the patient needs pain relief and wants something to be done for them, is it up to us to make decisions for them?” he said. “Are we possibly doing harm to the patient by implementing these limitations? Does everybody have the right to get treated the same, to have opioids prescribed to them if they need them?”
Education is still lacking he said, “and there is no question providers are more concerned with the impact on their licenses than the impact on pain.”
Zacharoff said patients with chronic pain live in fear, always feeling they need to prove that their pain exists, and many clinicians feel they are under regulatory scrutiny when treating patients with chronic pain.
“And patients on opioid therapy are considered problematic and on the edge of having a substance use disorder,” he said. “There’s a stigma. Patients feel like they’re wearing a scarlet letter. They get angry at the system and at the people who are supposed to be helping them.”
Zacharoff believes, however, that “we are starting to witness a bit of a reversal of the opioid pendulum. We witnessed liberal prescribing of opioids because people didn’t know what to do without proper education, increasing opioid deaths, then limits on prescribing. It’s starting to swing back to the middle.”
Zacharoff shared stories of two men who were being treated with opioids long-term for chronic pain. They began to encounter increasingly challenging obstacles to getting their prescriptions refilled, experienced pushback from insurance companies and physicians, and were faced with gaps in their medication or retraction of their prescriptions.
The first man felt compelled to obtain pain relief outside the medical setting and ended up overdosing on counterfeit medication. The other ended up committing suicide. This man’s family was awarded $7 million because a direct link was found between willingness to treat his pain and his suicide.
“Everybody is being instructed to decrease the amount of opioids being used,” Zacharoff said. “People who need them are afraid of being cut off.”
Those living with chronic pain often are unable to work and have difficulties just participating in the world.
“These patients often say that trying to function in daily lives is like having two jobs when you have chronic pain,” Zacharoff said. “Using opioids to facilitate participation in daily activities is not the same as addiction.”
The relationship between tolerance, dependence and addiction is unclear, he said.
Zacharoff defined tolerance as the body needing more of a substance over time to achieve a certain effect. Dependence is when the body adapts to the presence of a drug and experiences withdrawal symptoms if it is decreased or discontinued. Addiction is compulsive use despite awareness of harm.
“Patients are dependent on certain medications to function and contribute to society,” he said. “We need to think about the ethical considerations involved in tapering someone.”