Opioids

Should Dying Cancer Patients Suffer From Undertreated Pain Because of 'Concerns Regarding Addiction'?

Two recent studies show how ham-handed efforts to reduce opioid prescriptions undermine medical care.

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Two recent studies show how the attempt to curtail drug abuse by discouraging and restricting opioid prescriptions has hurt bona fide patients by depriving them of the medication they need to ease their pain. The harm inflicted on these innocent bystanders, which would not be morally justified even if the opioid crackdown did what it was supposed to do, is all the more appalling because limiting legal access to these drugs seems to have accelerated the upward trend in opioid-related deaths by driving nonmedical users toward black-market substitutes.

Jon Furuno, an associate professor of pharmacy practice at the Oregon State University College of Pharmacy, looked at prescribing patterns among 2,648 terminal patients who were transferred from an academic medical center to hospice care from January 2010 through December 2018. During that period, regulators and legislators responded to the "opioid crisis" by directly and indirectly limiting analgesic prescriptions, often in ham-handed ways. While that was happening, the study found, the share of hospice-bound patients who had opioid prescriptions when they were discharged fell from 91.2 percent to 79.3 percent—a 13 percent drop.

Furuno and his co-authors, who reported their results this month in the Journal of Pain and Symptom Management, controlled for age, sex, diagnosis, and the location of hospice care, so changes in those factors do not account for the decline in opioid prescriptions. Furthermore, "prescribing of non-opioid analgesic  medications increased over the same time period," meaning that pain was more likely to be treated with less effective but still potentially dangerous drugs.

The average age of these patients was 66. Nearly three-fifths had cancer diagnoses, and all of them were expected to die soon, meaning that treatment should have been focused on making them as comfortable as possible in their remaining time.

"Even among patients prescribed opioids during the last 24 hours of their inpatient hospital stay, opioid prescribing upon discharge decreased," Furuno noted in a press release. "It seems unlikely that patients would merit an opioid prescription on their last day in the hospital but not on their first day in hospice care, and it's well documented that interruptions in the continuity of pain treatment on transition to hospice are associated with poor patient outcomes."

Furuno noted that "pain is a common end-of-life symptom, and it's often debilitating." He added that more than 60 percent of terminal cancer patients report "very distressing pain."

In this context, it is especially striking that Furuno and his colleagues cite "patient and caregiver concerns regarding addiction" as one obstacle to adequate pain treatment. The risk of addiction is exaggerated and overemphasized even when physicians are treating chronic pain in patients who may have years or decades to live. When patients on the verge of death are suffering severe pain that could be relieved by opioids, "concerns regarding addiction" seem like a cruel joke.

Furuno et al. also mention "policies and practices aimed at limiting opioid use in response to the opioid epidemic," which are based on similar fears and reinforce them. In particular, Furuno cites the opioid prescribing guidelines that the Centers for Disease Control and Prevention (CDC) issued in 2016.

Those recommendations, which were widely interpreted as setting firm and binding limits, led to large, sudden, and indiscriminate dose reductions, along with outright cessation of treatment and patient abandonment. The suffering caused by that response has been highlighted by the American Medical Association, the Food and Drug Administration (FDA), and the CDC itself. The authors of the guidelines blamed clinicians who "misimplemented" their advice.

"There are some concerns…that indiscriminate adoption or misapplication of these initiatives may be having unintended consequences," Furuno said. "The CDC Prescribing Guideline and the other initiatives weren't meant to negatively affect patients at the end of their lives, but few studies have really looked at whether that's happening. Our results quantify a decrease in opioids among patients who are often in pain and for whom the main goal is comfort and quality of life."

A Journal of General Internal Medicine study published in February further illustrates how indiscriminate efforts to drive down medical use of opioids have undermined patient care. Researchers at Harvard and the University of Minnesota examined prescribing records for a 20 percent sample of Medicare patients treated from 2012 to 2017. They identified nearly 260,000 patients who were on long-term opioid therapy (LTOT) during that period and found that LTOT was discontinued in 17,617 of those cases.

"Adjusted rates of LTOT discontinuation increased from 5.7% of users in 2012 to 8.5% in 2017, a 49% relative increase," the researchers reported. In a large majority of cases, LTOT "stopped abruptly," and sudden cessation became more common during the study period, accounting for 81.2 percent of discontinuations by the end, up from 70.1 percent at the beginning. Two years ago, the FDA warned that such abrupt tapering may lead to "serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide."

Study co-author Michael Barnett, a physician and an assistant professor of health policy and management at Harvard's T.H. Chan School of Public Health, was dismayed by the frequency of such "off the cliff" dose reductions. "The vast majority of long-term opioid users whose therapy was discontinued had an extremely rapid, abrupt taper that was far outside of guideline recommendations," he told MedPage Today. "It would have been concerning to find that, say, one in four long-term opioid users had abrupt cessation of their therapy, but we found that it was most, even among those with very high daily doses of opioids."

Barnett concluded that "we need more education and support for patients on long-term opioid therapy to taper in a clinically rational way." But the speed of tapering is not the only concern raised by these findings.

Drug warriors may assume that all of these LTOT discontinuations would have been medically appropriate if only they had been carried out more gradually—in other words, that all of these patients were better off without the opioids they had long used to relieve their pain. But it seems unrealistic to suppose that doctors, operating under extraordinary government pressure, never sacrificed the interests of their patients to avoid unwelcome scrutiny. The increased risk of suicide among patients suddenly deprived of pain medication suggests otherwise.

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  1. When the headline is phrased as a question the answer is always “NO”

    1. Those who answer “yes” should be banned from ever being prescribed a painkiller.

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    2. Those who answer “yes” should be forever banned from having a prescription for painkillers.

    3. In Flanders Fields?

  2. Addiction is a dependence that causes problems. I don’t think that’s even really a possibility for people in extreme pain or in the process of dying.

    1. Zeb, don’t worry, be happy! Terminal patients need pain control? Let them have yoga! If they will just BELIEVE in yoga, all will be just fine! TRUST in your Government Almighty care-takers!

      https://www.health.state.mn.us/communities/opioids/mnresponse/nnpmgrant.html
      Opioids
      Non-narcotic Pain Management Mapping and Demonstration Projects (Yoga much mentioned)

      Yoga-Bear will bear your pain for you!!! TRUST in Yoga-Bear, JUST on Yoga-Bear! I swear!

    2. Flute-bitch aside, you can get into an actual argument about when too much drugging with painkillers also reduces the quality of life. Do you want to be at least semi-coherent in your final days? Or is it better to be as pain-free as possible?

      1. That should be up to the person in pain. When hospice comes in, they just try to keep the person comfortable until death. People in terrible pain aren’t coherent anyways.

      2. What does it matter what YOU want? Government Almighty will decide FOR you! And WHY is that? Because Nasty Nosenheimer and Butthole Buttinski and hundreds of other assholeish, self-righteous voters INSIST that, to satisfy their “punishment boners”, all of the BAD people MUST be punished! For ANYTHING that pisses off Nasty Nosenheimer and Butthole Buttinski, etc.!

  3. Senile Joe prefers his constituents to be addicts of imported chinese fentanyl.

  4. O said grandma could have her pain pill.

  5. If you like your doctor, you can keep your doctor. But not your pills.

    1. You didn’t make those pills.

    2. No pain, no gain.

  6. “Should Dying Cancer Patients Suffer From Undertreated Pain Because of ‘Concerns Regarding Addiction’?”

    Elitism is about politicians, academics, and bureaucrats using the coercive power of government to inflict their qualitative preferences on those who don’t share them. The question isn’t whether the experts are making the right choice. The question is why we give them the power to make qualitative choices on our behalf in the first place.

    Even if they could show that undertreating pain means less addiction nationally, there is no authoritative way to show that less addiction is qualitatively more important than less pain in any particular case. The only way to adequately account for everyone’s qualitative preferences is to let each of us represent our own when we make choices for ourselves.

    Here’s Narcotics Anonymous about how addicts should deal with illness and injury:

    “It is difficult for any doctor to provide us with adequate health care unless we are honest about our addiction. It is essential that we let our doctors know that we are recovering addicts. It may be necessary to tell them a little about addiction as we understand it. Most importantly, we make it clear that we choose not to take medication unless it is necessary. Our honesty will help our doctors accurately assess our needs . . . . While our doctors are responsible for our medical care, we are responsible for our recovery.

    https://moascna.naohio.org/InTimesofIllness.pdf

    Even Narcotics Anonymous seems to understand that these choices should be made on a person by person basis and a situation by situation basis–with each individual taking responsibility for their own tough choices, no matter what the expert Doctor says.

    People who ridicule doctors, academics, and bureaucrats who imagine that their qualitative preferences are somehow more authoritative than those of anyone else are absolutely right to do so. And those who want to inflict their qualitative preferences on the rest of us using the coercive power of government are evil in addition to being ridiculous–even if their intentions are supposedly good.

  7. I feel bad for pain patients. But it’s easy enough for them to put a stop to this nonsense. Just attend your local 12 Step meeting (AA/NA) and learn about the ‘disease’ that makes people have sex and drive drunk and come to meetings to brag about it. You’ll want to debunk their cult and end all the government restrictions designed to protect and promote it.

    1. It’s kind of like a kind of secularized version of Christianity, this idea that pain is good for your soul.

      1. But without the idea that the soul survives death, which makes it a little weird.

    2. What government protections does AA/NA have exactly? It’s a non-profit but so what? They receive no government funding, they don’t lobby for legislation, and they don’t go out and try to promote themselves or push their agenda on anyone. Show me on the little doll where AA touched you…

      1. A lot of people, especially in NA, are there because courts tell them they have to be. That might be part of what he’s thinking of.

        1. The courts and treatment centers forced AA and NA on people when according to the organizations themselves, it’s purely a personal choice to be there and they have no objections to people going elsewhere or using other paths for their recovery. It really was a misuse of the organizations by outside forces and created a lot of animosity toward them. AA and NA are mutual support groups – not treatment – and that is clear in their literature.

  8. I remember when Oxycontin and Duragesic patches started killing addicts in the ’90s. A Philly assemblyman made the news by saying if you have to choose between cancer patients and addicts, then “let them die”. I’d prefer they not die, but agreed then and agree now.

    For all the good intentions (questionable), opioid laws in my state have done a tremendous amount of damage.

    1. They have, particularly for those who have chronic autoimmune illnesses. = For all the good intentions (questionable), opioid laws in my state have done a tremendous amount of damage.

      1. Even if you have a long-term injury it’s affecting people.

  9. I was just released from the hospital after open chest surgery. I was sent home with 30 days of medicine for everything except pain killers. For that it was limited to 7 days. I asked the doctors if that would be enough since they had already said recovery would be 4-6 weeks. They said, to call back when it was out and they would try to get another 7 days worth.

    That’s ridiculous.

    1. Curently, I’m cutting the Oxycodone in half to stretch the supply.

      1. I still have my oxy from a back injury a few years ago, among other pain killers I’ve stockpiled.

        1. You two should get together.

    2. I actually think the restrictions hurt the medical industry – because people become risk averse and so avoid taking chances that could get them injured and left in untreated pain.

      For example, someone might decide not to go skiing. I certainly wouldn’t.

    3. I agree, but with the caveat that most folks are under the assumption that any time they go to the doctor or have discomfort, it’s a perfect excuse to take a pill. You can get long term f’d up with 30 days of Oxy, and short of untreatable cancer, there’s no need for it. Recovery period means till life gets back to mostly normal, not time to be spent under heavy sedation.

      Dying is a different matter. Let them go cold turkey after the coffin lid closes.

      1. Have you had a broken back, a broken neck, or ever had a serious injury requiring surgery? It takes years to get through treatment. During that time, the pain takes a severe toll on your mental state. Under proper pain medications, you can at least lie comfortably. Without them, you will be in agony at all times. Think about what that does to your mental state. Think about watching a family member in agony. Pain medications serve an important purpose, they provide quality of life. Without them, suicides and assisted suicides will increase exponentially.

      2. Some people get fucked up in 30 days. Some people stop taking it, fell a little sick for a few days and get over it. Addiction isn’t something that happens automatically when you take a drug for a certain amount of time. Most people, who have better things to do than take pills all day, will not become junkies because they took pain pills for a month.

    4. I had open heart surgery (valve repair) almost 3 years ago. In the afternoon of the surgery, fresh from being sawed in half, and with various tubes still sticking out of my chest/ abdomen (Borg-style), the pain was terrible, and they wouldn’t even give me a morphine IV. I got some NSAID pills, which took a while to work. On that first day after they hacked me in two, it was ridiculous to be stingy with real painkillers due to concern about addiction. By 48 hours after surgery, I was fine on just regular-strength tylenol, so I don’t think I was ever at much risk of spiraling into opioid despair. But that first day, especially that night, was unnecessarily miserable.

  10. I absolutely DREAD the day my back pain returns. It will, my neurosurgeon assured me of that, because of my severe disc herniation. I was literally crippled for over 3 months, and even WITH the hydrocodone, muscle relaxants and eating Aleve like candy, I wondered how long I could go on living with the extreme pain.

    If I got this pain again, I’m pretty sure the doctor seeing me would just make me *tough it out*.

    1. I was in that scenario for over a decade and a half. I had several botched surgeries and a half dozen other procedures. Then one day, I met the right doctor. He was disgusted at the “care” that I had received previously. He fixed it and now my world is new. I have not needed a pain medication since.
      Keep trying. Not all doctors and surgeons are at the same skill level. The hacks hired at the VA aren’t in the same class as the surgeon that finally fixed me.

    2. I was there too. I had an excellent neurosurgeon do a micro discectomy about two years ago and, in my case at least, it was definitely the thing to do. And they gave me adequate pain meds after the surgery. Before the surgery they tried to give me weird shit like neurontin, which didn’t do much but make me sleepy so I was eating way too much Advil.

  11. My body, government’s choice.

    1. Weed isn’t even legal.

      1. Yes it is, in multiple states.

        1. The Feds can bust you in all states.

    2. When lawyers dictate medicine, it’s not a good result.

  12. People should be allowed to do what they want except initiate force. It’s not that difficult of a concept.

    1. So for example, child neglect. You’re right. “It’s not that difficult a concept” and neither is the all-sugar diet. Simplicity doesn’t equal not stupid.

      When I see people who think large problems have a single cause or one rule can run a complex society, it tells me he’s likely a disappointment to his parents who are still supporting him.

      1. Don’t be absurd. Not caring for a child is force because you have complete control over them.

        1. It isn’t force. It’s the absence of any force.

  13. Defund the DEA.

    1. And the NEA. And the other NEA.

  14. But nobody really cares about the pre-dead.

    Yeah, I do get that counts all of us but the only ones who count are the ones who are most likely to survive to the next election and might actually vote. Don’t worry though, there’s a good chance your vote will count even if you’re dead in many places.

    1. What if you’re dead in your brain but no other places?

      1. Harvest organs and sell them? Like Planned Parenthood and the FDA?

        Best when they are fresh.

      2. Don’t knock it, it may really great. It would be like having a government job that you were never qualified for and can never be fired from. No brain or thought needed. You can just show up and collect a pay check. Thinking is overrated.

  15. I had some serious surgeries over the last year up here in Canuckistan. My pain management generally was quite good; at my last stay, they gave me 3 mg of slow-release Dilaudid for night & the same for the day. I felt no appreciable pain during my (month-long) recovery. They also gave me 70 pieces of 1 mg regular Dilaudid pills when released from the hospital; I still have about 5 of them after 6 weeks (& I don’t need them anymore).

    Of course I’m not into downers.

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  17. People in pain (especially terminal patients) and their loved ones will eventually push back on doctors in not so nice ways. Like someone above stated, there are decreased mental states during prolonged periods of pain and intolerance will take a completely different path.

    Then there will be a red flag law for those that are on pain meds and/or must surrender their arms in order to be prescribed the pain meds.

  18. Most docs are not very good at treating pain. It is one of those things barely covered in training. The focus is on diagnosis, treating disease and preparing for board exams.

    For most it is not what they signed up for. Also they are afraid to go beyond published guidelines. The state medical board is very scary and you don’t want to tangle with them.

  19. When sullum stays off the Trump crack, he does an excellent job covering libertarian issues.

  20. Presumably, the rationale for outlawing drugs of various kinds is to save people from the bad effects that they are not wise enough to figure out for themselves. One asks, how can that possibly apply to terminal patients? For that matter, how does that apply to anyone? Is there any evidence to show that drug addiction problems are diminished with criminalizing drugs, and that this outweighs the great societal harms created by drug Prohibition? Portugal seems to have the right idea.

  21. Yes, because it’s far more important that politicians “do something” about the “crisis” du jour

  22. This is an outrage, and one of the main reasons I am strongly opposed to government limitations on opioid prescriptions. The trial lawyers have also contributed greatly to this horror.

    Why is it okay for me to terminate a pregnancy – ending the life of another being – but not okay for me to die of an overdose? Don’t get me wrong, that isn’t my intention, but if you want to dose up and drift off, be my guest.

    There’s actually an appropriate fishing term: bycatch. Bycatch is all the fish and sea creatures caught in the net meant only for tuna. The other creatures are tossed aside to die – basically sea garbage. the government casts a net to catch, I don’t know, people who get high, and they catch all these innocents who are treated like refuse. Their pain doesn’t matter.

    Someday I will be old, and I will be sick, and I am so afraid that relief will not be available. The government would love to require all of us to remain sober at all times (see the CDC guidelines related to alcohol). In my opinion, requiring sobriety in this political climate is a violation of the 8th Amendment.

  23. The type, dosage & quantity of Rx opioid meds necessary to keep a terminally ill Pt somewhat comfortable during their last/final days should be determined by the treating physician & Pt. Uneducated, ignorant & corrupt Govt /politicians should NOT be allowed to have any input whatsoever in the treatment of PAIN. MILLIONS of folks are SUFFERING great HARM &/or DEATH @ the hands of anti-opioid zealots (aka ???????? govt). Total abolishment of the infamous 2016 CDC Guidelines for prescribing opiate meds needs to happen STAT!!!

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