Posted by & filed under Noah's Notes.

By now most people are fully aware of the role that opioid over-prescribing played in the development of the opioid crisis in the US. The 2016 CDC guidelines on opioid prescribing for chronic pain and Maine’s law limiting prescribing of high dose opioids (with exceptions, including for palliative and end-of-life care) were crucial to reversing that trend in our state and in creating a shift to safer, more evidence based treatments for chronic pain.  But this has also resulted in very challenging experiences for some people who have been on chronic daily opioids, most especially for those who have been on very high doses for long periods of time.  The work of “de-prescribing” or tapering of opioids is complex, requires time and patience, must include education for our patients and our care teams, and is best accomplished in partnership with our patients.  The US Department of Health and Human Services has published an important resource in support of this approach, and it can be found here: https://www.hhs.gov/about/news/2019/10/10/hhs-announces-guide-appropriate-tapering-or-discontinuation-long-term-opioid-use.html

Unfortunately there are some prescribers who have simply stopped prescribing altogether, pulling the rug out from under their patients and inducing unnecessary withdrawal symptoms.  Others have tapered patients too rapidly, or have dismissed patients when they react with anger and fear about such a change in treatment.  And when a provider departs or retires, leaving a panel of patients on long term opioids, the covering providers are left in a no-win situation wherein they may be asked to prescribe in a manner that they consider unsafe, or to have a very difficult ongoing conversation with a patient with whom they have no relationship.  It is also true that up to 1/3 of people taking opioids on a daily basis for a long time meet the criteria for Opioid Use Disorder (addiction to opioids).  This is a difficult concept for patients and providers to embrace, because our common concepts of addiction (loss of job, housing and relationships and criminal activity) is often not the case in these circumstances.  But as a medical diagnosis it is real and if we are unwilling to consider the diagnosis of Opioid Use Disorder and to treat it appropriately (typically with buprenorphine/naloxone, or “Suboxone”) we are doing a disservice to our patients and to our community.

Two recently published articles raise the possibility of another subset of people who have been on long term opioids, which they label as Complex Persistent Dependence (CPD).  These are people who will find tapering much more difficult, with marked worsening of pain, the development of withdrawal symptoms despite careful tapering, and emotional deregulation (loss of self-control) and depression as the taper is being undertaken.  People on higher doses for longer periods of time, those with mental illness diagnoses (including depression) and those who have a history of significant emotional trauma or PTSD may be more prone to CPD.  And it is possible that this group of people could have both their experience of chronic pain and the emotional disruptions of dose tapering significantly improved if they were treated with buprenorphine.  Because it is only a partial opioid agonist (that is, it fills the opioid receptors but does not induce the level of sedation or euphoria that opioids cause) and because it is long acting, buprenorphine can help control pain, reduce the risk of sedation and of accidental overdose, and once stabilized, tapering of the dose can be much better tolerated.  And the use of buprenorphine in this circumstance does not require special training (“X Waiver”).

The challenges of this work are evident, and it is difficult to manage in isolation.  I’m pleased that the Schmidt Institute, in partnership PCHC and with the support of the State of Maine can now offer, free of charge, the expertise of our interdisciplinary Controlled Substance Stewardship team to any provider or practice in the state, to assist them in this vital and sensitive work.  The model that has worked well within PCHC for over 6 years has the potential to improve outcomes and create a more satisfactory process for patients and for providers, as we move to a new era of chronic pain management.

jgrant

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