Pain treatment

A New Study Finds That Reducing Pain Medication Is Associated With an Increased Risk of Overdose and Suicide

The study highlights the dangers that government-encouraged "tapering" poses to patients on long-term opioid therapy.

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Substantially reducing the doses of pain medication prescribed for patients on long-term opioid therapy is associated with a threefold increase in suicide attempts and a 69 percent increase in overdoses, according to a study published this week in The Journal of the American Medical Association (JAMA). The study reinforces concerns that the "tapering" encouraged by federal guidelines as a response to the "opioid crisis" causes needless suffering among patients, leading to undertreatment of pain, withdrawal symptoms, and emotional distress.

Alicia Agnoli, an assistant professor of family and community health at the University of California, Davis, and five other researchers examined the medical records of about 114,000 patients who had been prescribed "stable, high doses of opioids," with a mean daily dose of at least 50 morphine milligram equivalents (MMEs), for at least 12 months. They identified more than 29,000 patients whose doses were subsequently reduced by 15 percent or more. They used hospital records to identify "overdose or withdrawal events" and "mental health crisis events," including depression or anxiety and suicide attempts, during follow-up periods of up to a year.

"Posttapering patient periods were associated with an adjusted incidence rate of 9.3 overdose events per 100 person-years compared with 5.5 events per 100 person-years in nontapered periods," Agnoli et al. report. "Tapering was associated with an adjusted incidence rate of 7.6 mental health crisis events per 100 person-years compared with 3.3 events per 100 person-years among nontapered periods." In other words, tapering was associated with a 69 percent increase in overdose events and a 130 percent increase in mental health crisis events. Suicide attempts were 3.3 times as likely when patients' doses were tapered.

It is hardly surprising that patients who had been receiving stable doses of opioids for an extended period of time—doses that presumably controlled their pain effectively enough that they could function reasonably well—would experience distress when their doctors suddenly decreed that they would have to get by with less medication. The results of this study are consistent with earlier research documenting the danger of such one-sided, politically driven decisions. A 2020 study of veterans found that "patients were at greater risk of death from overdose or suicide after stopping opioid treatment." Another study published last year found that discontinuation of opioid therapy was associated with an increased risk of heroin use.

The JAMA study is also consistent with numerous complaints from pain patients across the country who reported that their medication was arbitrarily reduced or cut off in response to the prescribing guidelines that the Centers for Disease Control and Prevention (CDC) published in 2016. As Agnoli and her co-authors note, the CDC "recommended against higher doses of opioids in managing chronic pain and recommended dose tapering when harms of continued therapy outweigh perceived benefits for individual patients."

Although the CDC's advice was not legally binding, and although the guidance said doses should be tapered only when medically appropriate, doctors, lawmakers, insurers, and pharmacies interpreted the agency's warnings about daily doses exceeding 90 MMEs as a hard limit. "These and other widely disseminated recommendations have led to increased opioid tapering among patients prescribed long-term opioid therapy," Agnoli et al. note.

The consequences have been repeatedly decried by the American Medical Association (AMA). "The 2016 Guideline is hurting patients," AMA Board of Trustees Director Bobby Mukkamala said in a July 22 letter to the CDC. "Patients with painful conditions need to be treated as individuals. They need access to multimodal therapies including restorative therapies, interventional procedures, and medications. These include non-opioid pain relievers, other agents, and opioid analgesics when appropriate. Instead, patients with pain continue to suffer from the undertreatment of pain and the stigma of having pain. This is a direct result of the arbitrary thresholds on dose and quantity contained in the 2016 CDC Guideline. More than 35 states and many health insurers, pharmacies, and pharmacy benefit managers made the CDC's 2016 arbitrary dose and quantity thresholds hard law and inflexible policy."

In an April 2019 "safety announcement," the Food and Drug Administration (FDA) said it had "received reports of serious harm in patients who are physically dependent on opioid pain medicines suddenly having these medicines discontinued or the dose rapidly decreased." It said the consequences "include serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide."

The CDC itself joined the FDA in warning doctors about the hazards of abrupt dose reductions. "The recommendation on high-dose prescribing focuses on initiation," then-CDC Director Robert Redfield said. "The Guideline includes recommendations for clinicians to work with patients to taper or reduce dosage only when patient harm outweighs patient benefit of opioid therapy." Furthermore, "the Guideline also recommends that the plan be based on the patient's goals and concerns and that tapering be slow enough to minimize opioid withdrawal."

Even the authors of the guidelines worried that their advice had been "misimplemented" in a way that was hurting patients. "Unfortunately, some policies and practices purportedly derived from the guideline have in fact been inconsistent with, and often go beyond, its recommendations," Deborah Dowell, Tamara Haegerich, and Roger Chou wrote in a 2019 New England Journal of Medicine commentary. Those policies and practices, they said, included "inflexible application of recommended dosage and duration thresholds and policies that encourage hard limits and abrupt tapering of drug dosages, resulting in sudden opioid discontinuation or dismissal of patients from a physician's practice."

The CDC is mulling revisions to its advice. "A revised CDC Guideline that continues to focus only on opioid prescribing will perpetuate the fallacy that, by restricting access to opioid analgesics, the nation's overdose and death epidemic will end," Mukkamala warned in his letter to the CDC. "We saw the consequences of this mindset in the aftermath of the 2016 Guideline. Physicians have reduced opioid prescribing by more than 44 percent since 2012, but the drug overdose epidemic has gotten worse."

Whatever the revised guidelines say, the damage already has been done, and policies based on the original version will be difficult to unwind. Furthermore, the CDC's recommendations, while highly influential, were just one part of a broader strategy, implemented at the state and federal levels, to reduce opioid-related deaths by discouraging prescription of pain medication.

How has that worked out? Agnoli et al. note that "opioid-related mortality has continued to rise," which is a bit of an understatement.

The government indisputably succeeded in driving down prescriptions. Per capita opioid prescriptions in the United States, which began rising in 2006, fell steadily after 2012. Yet in 2019, when the dispensing rate was lower than it had been since 2005, the U.S. saw more opioid-related deaths than ever before. Last year, according to preliminary estimates from the CDC, that record was broken once again: Opioid-related deaths jumped by 40 percent. As opioid prescriptions fell, the upward trend in fatalities not only continued but accelerated as nonmedical users replaced legally produced, reliably dosed pharmaceuticals with highly variable black-market drugs of unknown provenance and composition.

Even if it were ethical to demand that patients live with treatable pain as the price of reducing opioid-related deaths (which it isn't), the government has not achieved that tradeoff. Instead we have worse outcomes across the board: many more patients suffering from pain that could be relieved and many more drug-related deaths. Far from harm reduction, this looks like a strategy of harm maximization.

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  1. Reducing Pain Medication Is Associated With an Increased Risk of Overdose and Suicide

    If it saves one life…

    1. “A single death is a tragedy. A million deaths are a statistic.”—I.V. Stalin
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          1. Not much.

          2. A traditional newspaper has two different sets of editors, and there is very little overlap in either personnel or function between them.

            One set of editors proof reads the work of the people who write articles.

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  2. 15 years ago I had family who were addicted to prescription pain killers. Their doctor likely knew it, but helped manage that addiction while also treating very real pain problems.

    Today, because the government “knows better” I have family who are addicted to black market pain killers, with no doctor oversight.

    But now everyone wants to talk about evil opioid drug companies- not the draconian effects of prohibition writ large.

    1. Was there any evil on the part of the drug companies? If so, what?

    2. I have family that’s been addicted to rx pain killers for 30 years and their life is a complete waste. The pain was very real at one point, I’m not buying it anymore.

    3. Opiates NEVER addicted anyone. For our uses “addiction” is a medical term. Only 4 in 1000 have the genetic predisposition to TRUE ADDICT to any opiate. We can see it in the CYP450 enzyme group. 996 out of 1000 exposed to an opiate will NEVER addict. Withdrawals is not EVIDENCE of addiction of any kind. Everyone withdraws. LEAVE INCURABLE SEVERE PAIN SUFFERERS OUT OF ‘opioid crisis’. ILLICIT USING AND True opiate addiction is a completely separate issue.

  3. I am one of the ones who live in pain and have been on norco for over 25 years. The comp company stopped paying for my medication over these BS government recommendations that say I am not in enough pain for their liking. My doc still prescribes because he knows the truth. To make it worse, the feral govt blames folks like me for the opioid epidemic. Law abiding old man here trying to have some quality of life.

    1. I hear you. Somehow people who take care of their homes, work and are productive parts of society must have that ripped because of addicts and their families who need someone to blame for their family members addiction Eric is a mental illness. Instead they would rather millions suffer from conditions that are non curable because they feel they are doing something to deal with their anger. I’m sorry their family members were addicts but we are not. I’m sick of being treated like one and having my life dangling in front of me cut off chunk by chunk. People don’t also understand your don’t walk in and get handed an opioid. It takes years of EVERYTHING failing. There is no other option. It’s that or suicide.

  4. This shit is terrible. Doctors probably were a little too free with opioid prescriptions for a while there, but now it’s the opposite extreme. There are a lot of people for whom what for most people would be a very high dose of opioids makes life bearable. I know a former commenter from here who is a highly respected psychiatrist and who takes enough oxycodone every day to kill most of us to manage pain. Without it he couldn’t do amazing work that is helping a lot of people. There are a lot of people in similar positions.
    So, yeah, maybe don’t prescribe vicodin when advil would probably work. But for some people there is no other way to be functional and not in constant pain. Even if some such patients are addicted in some sense, being a functional addict seems highly preferable to constant pain and misery.

    1. With carfentenal an amount smaller than a grain of salt can kill a person through skin absorption.

      Do you want freaks walking around in public with this shit? I don’t.

      Hell the US invaded Iraq, killing tens of thousands and destroying the cradle of earths civilization over false rumours of WMD.

      People addicted to opiates are like people on steroids, except instead of inhibiting the bodies natural steroid production opiates inhibit the minds natural ability to perceive reality. It can only be reversed under medical supervision.

      1. Do you want freaks walking around in public with this shit? I don’t.

        That’s fine. Everyone has an opinion. All we ask is that you stop calling yourself a “libertarian;” you are an authoritarian. Period.

        1. I’ve got your attention, good. It’s called free speech and you can choose to shut the fuck up.

          In fact, you might as well because if you don’t value truth nothing you can say needs to be heard.

          I never called myself a libertarian or anything else. Cite where I have. Crickets.

          Tell me, is it easier to be a two dimensional bigot?

        2. Tell me, is your circle jerk achieving your objectives?

          I’ve never seen a libertarian here admit that they can’t refute the truth.

          I can, and I’ve refuted your bullshit.

    2. There’s no such thing as prescribing freely. I wish people would stop chiming in on things they have no clue how it works. You just don’t walk in and say hey can I get some of those opioids. That goes back at least 15 years. They make you suffer for years before you could get any real relief. Then you get it and have it ripped away with your life. EVERYONE is one injury away or a defective gene rearing it’s head and no one can detect it treating you like it’s all in your head because it won’t show in an MRI or x-ray or bloodwork. This is an act of torture and a violation of human rights. What is a high dose for one may not even touch pain for another that has to do with your genes and being an ultra rapid metabolizer. Sadly Drs are too stupid to know anything about pharmacogenetics.

  5. This is a “no sh*t, Sherlock” statement. Of course, it increases the chance of overdose and suicide! The opiod prescription, when taken as prescribed, was allowing many people with chronic pain to live an almost normal life. It reduced the pain to the point it wasn’t overwhelming the brain. Then, doctors suddenly reduced or totally cut off access to the drug. Patients were either required to go to the black market to get something to reduce the pain, which increased the chance of a fentanyl overdose, or they tried to live with it. Living with constant pain is hard. It overwhelms every thought in your brain. Some people get to the point they can’t live with the pain anymore.

  6. #defundCDC

    1. Better to defund the CDC than the cops. That is for sure.

      1. Save more lives, also for sure.

        1. The CDC is actually a very helpful resource when they stick to their original mission of compiling data concerning infectious disease and other causes of morbidity and mortality. People are just hating on them now because of the Covid response which has gone overboard. The MMWR this week for example only contains one non Covid related article.

  7. “a strategy of harm maximization.”

    Sounds about right for government work…

  8. I couldn’t get pain meds for my back, so I used alcohol. Which lead to 22 years of alcoholism. But at least I’m not addicted to opioids.

  9. Getting off narcotics allows people to muster the energy to kill themselves

  10. At the federal level it’s all ILLEGAL mandates. We the people never gave that level of government authority over anyone’s health nor drugs.

    OBEY the U.S. Constitution!!

    1. It is the state medical boards who are doing the regulating, not the federal government.

      1. All of which have been subsumed by the Federal government many long years ago.

        The States are basically powerless at this point. I am not giving them a free pass, but like the BS of seatbelts, the Feds have so much money and power that they can override local decisionmaking.

    2. The Pure Food law that caused the Panic of 1907 is precedent for a lot of this stuff. Some states banned Rockefeller’s Glucose Trust from calling glucose “corn sugar,” others banned margarine. Pretty soon the fix was in with the 18th and 21st Amendments.

  11. Thanks to the corporate press and its symbiosis with Washington authoritarians for manufacturing a “crisis” that is nothing more than another moral panic. This latest evidence of a pathological “drug policy” is par for the course.

    If an opiate addict gets enough, he causes absolutely no problems for anyone and can live a relatively normal life, trudging to work every morning and coming home to TV, supper, and the old lady with the rest of “normal” society, only he has a cushion against pain and boredom. The biggest problem for an addict is a lack of supply.

    The animals who choose to shoot up and nod on the streets would be sociopaths whether they were junkies or not, and their insanity would no doubt find other nasty forms of public expression. Arrest for public intoxication and disturbing the peace would be as effective as a possession bust for such a creature.

    The state has been fucking with doctors and compounding the misery of addicts since the Harrison Act of 1914.

    1. “The state has been fucking with doctors and compounding the misery of addicts ”

      The doctors have been treating people in pain by prescribing drugs that turn them into addicts, only adding to their woes with costly and long lasting problems.

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  13. What has happened is criminal. Everyone saw this coming except the bureaucrats. Everyone.

  14. A New Study Finds That Reducing Pain Medication Is Associated With an Increased Risk of Overdose and Suicide
    The study highlights the dangers that government-encouraged “tapering” poses to patients on long-term opioid therapy

    So if reducing pain medication didn’t increase the risk of overdose or suicide, government mandates would be OK with you?

    What exactly is your argument here?

    Whatever it is, it’s not a libertarian argument.

    1. “Far from harm reduction, this looks like a strategy of harm maximization.”

      No, it’s a strategy of economizing. Reducing dose should be accompanied by an increase in other forms of therapy.That costs money of course.

    2. “Whatever it is, it’s not a libertarian argument.”

      Let doctors be doctors. It’s the ultimate libertarian argument.

      1. Saying “implement policy X because it reduces harm” is not a libertarian argument.

        1. That’s not the argument being outlined here.

  15. Is this by Jacob Sullum or Joseph Heller?

  16. One more reason to get government out of medicine.

    1. It was doctors who got people addicted in the first place. Get doctors out of medicine. Time for nurses to step up.

      1. I’ve been given opioids by doctors and thrown them out.

        Doctors don’t get people addicted, doctors offer drugs to you. It’s your choice whether you take them.

        1. ” It’s your choice whether you take them.”

          People choose to go to doctors hoping to have their underlying problems dealt with. If doctors are unwilling or unable to treat the underlying problems and only offer symptomatic pain treatment, then addiction is inevitable. Most people, not having medical expertise, will be inclined to defer to a doctor’s advice, especially if they have taken the trouble to make an appointment, visit the doctor’s office and submit to an examination.

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  18. I had angioplasty on my leg; the doc gave me fentanyl to keep me comfortable. I know for a fact that I had a conversation after the procedure with the doc, but I couldn’t remember much of what was said. 🙂

  19. Hum. Legalize everything, but it’s your responsibility.

    Also, maybe stop prescribing opioids for every stubbed toe and put the Sacklers on a diet?

    1. You really, I am sorry, you really, really do not understand. You can never party with opiates, the ‘price’ (withdrawals) is to high to pay for pleasure users.

  20. The best this column can conclude is that opiates shouldn’t be practiced

    1. Ok, say again please????

  21. Yes. These shallow fools are messing with real PAIN. “Chickens come home to roost”… “Everything comes around”. “There is NOTHING new under the Sun”…

  22. Opiates NEVER addicted anyone. For our uses “addiction” is a medical term. Only 4 in 1000 have the genetic predisposition to TRUE ADDICT to any opiate. We can see it in the CYP450 enzyme group. 996 out of 1000 exposed to an opiate will NEVER addict. Withdrawals is not EVIDENCE of addiction of any kind. Everyone withdraws. LEAVE INCURABLE SEVERE PAIN SUFFERERS OUT OF ‘opioid crisis’. ILLICIT USING AND True opiate addiction is a completely separate issue.

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