This is part of a letter sent to a hospital after patients were informed that their opioid scripts would be suddenly discontinued following a doctor’s retirement. I told the hospital that I was sending a copy of the letter to the news director at my state’s public radio station. Hospitals (and insurance companies) don’t want to make bad news.
In this case, the hospital agreed to contact the affected patients’ primary care providers to ensure patients continued to receive their medications until a full-time specialist could be hired. Of course, the new provider might decide to adopt a practice-wide ban, and patients would be left in the lurch again. In July 2019, the Journal of the American Medical Association reported that 40% of primary-care doctors refused care to patients on long-term opioids (link below). Feel free to use this letter and/or this research if you’re in a similar fight. I’d be interested in your struggle–and your success–on this important fight for fairness for people in pain. I’m on Twitter (links below).
—Jill Piggott, PhD Director, headsUPmigraine
I understand the doctors you’ve contracted to cover your hospital’s neurology practice until a full-time specialist is hired have refused to maintain any of the opioid scripts established by the doctor. I’m sure you’re aware that it’s not safe for patients to abruptly stop taking opioids and that you’d be violating the CDC opioid prescribing guidelines if you forced patients off opioids without their consent (see “CDC Advises Against Misapplication of the Guideline for Prescribing Opioids for Chronic Pain” linked below).
The CDC’s recent reaffirmation that it never intended for patients to be abandoned or forced off opioids came in response to a letter from Health Professionals for People in Pain which reads in part: “Patients with chronic pain, who are stable and, arguably, benefiting from long-term opioids, face draconian and often rapid involuntary dose reductions. … Consequently, patients have endured not only unnecessary suffering, but some have turned to suicide or illicit substance use. Others have experienced preventable hospitalizations or medical deterioration” (see link below).
Disease progression can occur in illnesses that cause chronic pain if the patient’s symptoms are untreated. Consequently, even relatively short-term gaps in treatment can lead to long-term and even permanent disability. The hospital needs to recognize the legal jeopardy it’s in if you abandon patients and refuse them appropriate, effective care. Medical providers can be held liable for patient abandonment if care is terminated without reasonable notice or reasonable excuse and if the provider fails to provide the patient with a reasonable opportunity to find qualified replacement care. Providers should give patients written notification of termination and continue to offer care for a reasonable period.
The Food and Drug Administration has identified harms caused by the sudden discontinuation of opioids or by rapid decreases in dose, including “withdrawal symptoms, uncontrolled pain,
psychological distress, and suicide.” In new labelling, the FDA explicitly states that “Health care professionals should not abruptly discontinue opioids in a patient who is physically dependent” (see link below).
The FDA advises physicians to obtain patient consent before discontinuing or tapering the dose of opioid analgesics and instructs them to “consider a variety of factors, including the dose of the drug, the duration of treatment, the type of pain being treated, and the physical and psychological attributes of the patient.” Physicians should “create a patient-specific plan to gradually taper the dose of the opioid and ensure ongoing monitoring and support, as needed, to avoid serious withdrawal symptoms, worsening of the patient’s pain, or psychological distress.”
There are “no standard opioid tapering schedules that are suitable for all patients,” but the shortest acceptable taper is in increments of “no more than 10 percent to 25 percent every 2 to 4 weeks.” However, “if the patient is experiencing increased pain or serious withdrawal symptoms, it may be necessary to pause the taper for a period of time, raise the opioid analgesic to the previous dose, and then once stable, proceed with a more gradual taper.” Finally, the FDA expects physicians to “ensure that a multimodal approach to pain management, including mental health support (if needed), is in place prior to initiating an opioid analgesic taper.”
Perhaps most alarming is the FDA’s assessment that the withdrawal symptoms associated with an abrupt discontinuation or too-rapid taper “can lead patients to seek other sources of opioid pain medicines, which may be confused with drug-seeking for abuse. Patients may attempt to treat their pain or withdrawal symptoms with illicit opioids, such as heroin, and other substances.”
The hospital has failed to follow current FDA guidance on prescription opioids. You haven’t notified patients, much less obtained consent. You haven’t asked providers to develop patient-specific plans. You haven’t educated patients about the potential range of health- and life-threatening harms of opioid discontinuation or rapid tapers. And the clock’s running: opioid scripts are only 30 days long, so you have an entire practice of neurology patients facing health emergencies of your making within the next 4 weeks.
When will you notify patients about this possible termination of treatment? How will you gain patient consent before initiating any tapers? Will you provide patients full and accurate information about the grave risks posed by sudden discontinuation or rapid tapers?
Who will ensure the hospital’s compliance with FDA labelling guidance if your substitute neurologists will not? Has the hospital asked full-time primary care physicians to continue well-established opioid scripts?
The hospital has failed to comply with the FDA directive to have a “a multimodal approach to pain management” in place “prior to initiating an opioid analgesic taper.” What emergency, mental health, and/or in-patient services will the hospital provide to patients if they’re suddenly forced off treatment without their consent? Will the hospital provide these services free of charge to impacted patients?
Who is responsible for ensuring continuity of care, and how can I reach that person?
● “CDC Advises Against Misapplication of the Guideline for Prescribing Opioids for
Chronic Pain.” US Centers for Disease Control. 24 April 2019.
● “Health Professionals Call on the CDC to Address Misapplication of its Guideline on Opioids for Chronic Pain through Public Clarification and Impact Evaluation.” Health Professionals for People in Pain. 6 March 2019. healthprofessionalsforpatientsinpain.org/the-letter-1
● “FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering.” US Food and Drug Administration. 9 April 2019. https://www.fda.gov/drugs/drug-safety-and-availability/fda-identifies-harm-reported-sudd en-discontinuation-opioid-pain-medicines-and-requires-label-changes
● “Access to Primary Care Clinics for Patients With Chronic Pain Receiving Opioids.” PA Lagisetty, et al. JAMA Network Open. 12 June 2019. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2737896
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Abandonment, Forced Opioid Tapers, Jill Piggott, PhD Director, headsUPmigraine, Journal of the American Medical Association, CDC, Advises Against Misapplication, Guideline, Prescribing Opioids for Chronic Pain