In the June 14th Wall Street Journal, Johns Hopkins University bioethicist Travis Rieder, in an excellent essay, shared with readers his battle with pain resulting from a devastating accident, the effectiveness of opioids in controlling the pain, and the hell he went through when he was too rapidly tapered off of the opioids to which he had become physically dependent. Like most patients requiring long term pain management with opioids, he developed a physical dependence, which is often mistakenly equated with addiction by policymakers and many in the media.
The aggressive schedule launched me into withdrawal, and I learned viscerally, firsthand, what the absence of opioids can do to someone whose brain has become accustomed to them. Those symptoms include increased sensitivity to the very pain that the opioids counteract, as well as extreme flu-like symptoms, insomnia and crippling depression. I came to understand why people sometimes go back onto deadly dangerous drugs: because the alternative is such profound suffering that it makes you want to die.
I have criticized policymakers for their ham-handed approach based upon a misinterpretation and misapplication of the guidelines on pain management with opioids, released in 2016 by the Centers for Disease Control and Prevention, here, here, and here. As explained in an article I co-authored in the Journal of Pain Research in February 2019, this blunt reaction is based upon the false assumption that opioid-related overdose deaths from nonmedical use is primarily a result of doctors treating patients in pain.
In his essay, Dr. Rieder levels similar criticisms:
Perhaps the greatest challenge about them [opioids] today is to resist the urge to be simplistic or reactionary. America’s current crisis of overuse has led some prescribers to avoid the drugs completely, and it has led politicians to occasionally consider ham-fisted policy solutions, like limiting the lengths or dosages of prescriptions regardless of any individual patient’s needs. But when a medication has both risks and benefits, what we need isn’t one-size-fits-all policies but nuance.
Dr. Rieder was one of dozens of scholars, academics, physicians, and pain experts who signed a letter to the Oregon Health Authority in March, authored by Stanford University Medical School Professor Sean Mackey, urging against the Authority's plans to force a rapid tapering off of opioids on all of the chronic pain patients in Oregon’s Medicaid system. That letter, plus push-back from patient advocacy groups, caused the Oregon Health Authority to put its plans on hold. It should not be lost on readers of this blog post that such interventions in the practice of medicine and the delivery of health care are part and parcel of a state-run health care system.
Towards the conclusion of his essay, Dr. Rieder touches upon this subject of chronic pain patients whose pain is controlled or managed with long term opioid therapy, warning policymakers to avoid the temptation to impose rapid tapering regimes, as was contemplated in Oregon.
Finally, physicians must compassionately engage with so-called “legacy” patients—those who, thanks to aggressive prescribing and overprescribing, have been on opioids for years or even decades. Taking the drugs away can send them into debilitating withdrawal, and the correct course of action isn’t clear. The overdose crisis is no excuse to be callous about their suffering.
I wish Dr. Rieder would have stated more explicitly in his essay that many chronic pain patients continue to require opioids long term in order to manage their severe pain, and in those cases, nothing else works for them. Their maintenance on chronic opioid therapy allows them to have a functional and meaningful life. There is nothing morally or medically wrong with them being maintained indefinitely on appropriately dosed and managed opioid therapy. Many opioid addicts receiving Medication Assisted Treatment (MAT) with methadone are maintained on that powerful opioid indefinitely.
I have a few personal friends who are very successful and lead happy and productive lives, and have been regularly taking stable doses of hydrocodone or oxycodone for years in an amount sufficient to manage their chronic pain without clouding their cognitive abilities. Such is the case with many chronic pain patients managed long term on opioids. These people don't want or need to be tapered off their opioids and, from a medical standpoint, there is no reason why they must be tapered off. Requiring them to eventually taper off of their pain medication could throw them back into a life of pain, suffering, and inactivity.
Some readers of the essay might come away, like I did, with the impression that Dr. Rieder believes that all patients maintained on opioids for their pain should eventually be tapered off of the drugs, but that it should be done in an individualized, nuanced, and humane way, free from one-size-fits-all directives from legislators or regulators. While I am grateful for his efforts in support of humane, evidence-based approaches to the use of opioids for the management of pain, and I am deeply sympathetic to his personal ordeal with pain, I hope I am misreading him on this particular point.