In recent years, chronic-pain patients on long-term opioid therapy have been living in fear. They fear being abruptly cut off from their medication by doctors who no longer feel comfortable prescribing opioids. They fear the prospect of withdrawal and a life of pain.
We now have evidence that these fears are eminently reasonable. Across the country, clinicians have changed their prescribing practices, requiring that patients taper abruptly to a lower dose or discontinue their opioid medication altogether, sometimes under threat of being “fired” from their clinic if they don’t comply.
I know this not only from media reports but also from recent acknowledgment of the problem from the Centers for Disease Control and Prevention and Food and Drug Administration. I also know it because patients tell me. Ever since I went public with my own account of opioid dependence and the horror I experienced in withdrawal, I’ve collected heartbreaking stories from desperate patients. I’m approached after talks by audience members who want to share intimate details of their loved ones’ pain, medical histories and eventual abandonment. Other patients send me emails or handwritten notes, desperate for advice to relieve the pain and withdrawal they’ve been left in.
This is not how cases of long-term opioid therapy should be handled; our fear of opioids should not lead clinicians to abandon or forcibly taper their patients. Fortunately, the Department of Health and Human Services has now officially agreed, issuing a Guide for Clinicians on the topic of opioid tapering. The purpose of the guide is actually twofold: It teaches clinicians how to taper chronic opioid therapy (something for which there is a clear need), but it also directs clinicians not to taper opioids abruptly and nonconsensually (and not to abandon opioid therapy patients altogether).
It’s worth noting how strong a stance the department is taking with this second part of the guide. A central problem with pain medicine today is that there is a population of patients who, thanks to a history of aggressive use of opioids for chronic pain, are on high doses of opioids.
It is sad the government has no empathy for people with legitimate pain issues, so they apply their “scorched earth” policy on all patients, and make doctors afraid to prescribe appropriate levels of pain management. I run 18 hours a day, 7 days a week in TV production and filming and typically wake up 5-6 days a week with a migraine already started. Imitrex works well but it takes an hour to achieve efficacy. That hour can be crucial, as my migraines continue to build until I go into the nausea and vomiting every half hour for the next 16 hours. If I feel I can’t make the hour wait, I often have to take 1 hydrocodone pill as it goes to work in about 20 minutes. If I feel I can make the hour, I only take Imitrex, but if I’m liable to be vomiting before the hour is up, I have to take 1 hydrocodone to cap the pain and nausea. All the hydrocodone does for me is help the building pain subside, I don’t get buzzed, high, impaired or euphoric over it, and I can continue to function and get on with my work. My neurologist, who I have been with for 20 years, prescribes 200 hydrocodone, but it has to last 7 months, and regular office visits are required, with urine tests at each visit. I usually have excess prescription left over, and I have never felt “addicted” to it. I doubt any professional would find my use, or my doctor’s prescription, abusive or excessive. I travel a lot and you cannot transfer a hydrocodone prescription to another pharmacy so the supply is carefully and responsibly managed to get me through 7 months. My neurologist is comfortable with the treatment, but at the same time he certainly doesn’t want to invite government inquiries into his responsible practice, so he apologizes to me and I’m the one left holding the bag. I wish all these bureaucrats who believe everyone is a drug addict could experience the joy of throwing up every 30 minutes for 16 hours straight. Perhaps if they went after the pill doctors selling prescriptions out the back door instead of scaring responsible doctors and responsible patients, impacting effective treatment and pain management, they just might solve the issue; but I guess killing all the patients with a broad brush is easier to do than go after doctors who abuse their authority. What is abusive is the government thinking they can solve anything. Everything they touch, becomes a disaster for responsible people.