How do we support people living with chronic, non-cancer pain to lead healthy, happy, harm-free lives? This question stumps many clinicians and researchers, as conflicting data seems to come out every year. Start opioids, because we are under-treating pain. Decrease opioids, because they don’t actually improve pain and function. Stop opioids altogether, because otherwise patients will become dependent on or addicted to them.
To help clinicians navigate the myriad of data and implement evidence-based care, the Centers for Disease Control issuedguidelines in 2016 with new recommendations to decrease or taper patients who are on high doses of opioid pain relievers. While the implementation of the guidelines was associated with anticipated declines in dangerous prescribing practices and opioid prescriptions, a rise in heroin overdose deaths was also observed shortly thereafter.
Phillip Coffin and a multidisciplinary team of researchers at the Center on Substance Use and Health set out to study this conundrum, of whether reduced access to prescription opioid pain relievers leads to increased illicit opioid use (including both heroin and non-prescription opioid pain relievers). Hot off the press are the results from their retrospective cohort study, which was conducted with 602 publicly-insured primary care patients in San Francisco who had been prescribed opioids for chronic non-cancer pain for at least three months in a row. A combination of historical reconstruction and medical chart abstraction procedures were used to compare the frequency of heroin and non-prescribed opioid pain reliever use between participants who experienced changes in their opioid prescription (discontinuation or 30% increase or decrease in dose) and those with no changes.
The results were straightforward and sobering. Participants whose prescribed opioids were discontinued had an increased likelihood of using both heroin and other non-prescribed opioid pain relievers more frequently than participants with no change in their prescription dose (at adjusted odds ratios of 1.57 and 1.75 respectively). In other words, when a provider cuts off a prescription opioid altogether, that doesn’t mean the participant is stopping opioids; oftentimes, the patient just has to find other ways to treat their pain or dependence on opioids. In this era of staggering overdose death rates and the rise of potent fentanyl, the risks of harm when patients turn to illicit opioids are many. And even more troubling, out of the 237 patients who experienced at least one opioid discontinuation, only five (0.02%) reported starting treatment for opioid use disorder with a medication like buprenorphine.
Interestingly, over the course of the study period (2012-2017/8), participants whose prescription opioid dose increased were also found to use heroin more frequently. This finding was noted among patients who were already using heroin. This suggests that the clinical decision to try a higher dose of opioid pain relievers may similarly do more harm than good. The study authors could not determine the reason for this finding but offer possible explanations; for instance, patients may supplement opioid pain relievers with heroin when pain worsens, develop increased tolerance to opioids, or exchange prescribed opioids for heroin.
While causality cannot be established from retrospective studies like this one, certainly the association is obvious: stopping prescription opioids completely carries real risks. The findings of this study serve as a resounding alarm to clinicians that discontinuing opioids can have unintended, harmful consequences. In fact, the CDC published an advisory discouraging the misapplication of their guidelines by abrupt tapering or sudden discontinuation of opioids since “these practices can result in severe opioid withdrawal symptoms including pain and psychological distress, and some patients might seek other sources of opioids”. Instead of just stopping opioid prescribing, clinicians must move towards shared decision-making, appropriate screening and treatment for opioid use disorders, and implementation of strategies like opioid tapering to promote the health and well-being of patients living with chronic pain.
Bohnert ASB, Guy GP, Jr., Losby JL. Opioid Prescribing in the United States Before and After the Centers for Disease Control and Prevention's 2016 Opioid Guideline. Annals of internal medicine. 2018;169(6):367-75. doi: 10.7326/M18-1243. PubMed PMID: 30167651; PubMed Central PMCID: PMC6176709.
 CDC Advises Against Misapplication of the Guideline for Prescribing Opioids for Chronic Pain.Media statement. Accessed 05/05/2020. https://www.cdc.gov/media/releases/2019/s0424-advises-misapplication-guideline-prescribing-opioids.html