Patient Abandonment & Forced Opioid Tapers
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. The hospital agreed to contact the primary-care physicians of every affected patient to ensure continuity of care. 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
First sentence depends on the situation:
I understand your hospital [or practice] allows doctors to refuse to treat patients who rely on opioids to manage disabling pain. This forces patients to discontinue an effective medication and puts them at risk of significant harm.
I understand your hospital [or practice] allows doctors to taper patients off opioids without their express consent.
If you’re the patient, write an opening that makes this clear. For instance:
For nearly a decade, Dilaudid has allowed me to manage disabling, daily migraine. Without it, I’m basically bedbound and can’t reliably get to the hospital or doctors’ offices for care. I’ve just learned that the neurologists you hired to cover Dr. —’s practice refuse to continue opioid prescriptions for his patients. I’m not well enough to travel long distances to find a specialist willing to weigh the benefit of opioid treatment for people with chronic, intractable pain like me. As a result, in less than 4 weeks, I’ll be forced off the only effective pain relief I’ve found.
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.”
Your hospital fails to follow current FDA guidance on prescription opioids whenever patients are forced to taper without their consent, when they are denied the ability to control the timing of a taper, or when they are abandoned for discontinuing a taper. Who is responsible for continuity of care and for ensuring the hospital follows FDA policy on opioid prescribing? I’d like to be in touch with that person directly.
I appreciate your attention.
“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.
“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.
“Access to Primary Care Clinics for Patients With Chronic Pain Receiving Opioids.” PA Lagisetty, et al. JAMA Network Open. 12 June 2019.
CDC Advises Against Misapplication of the Guideline for Prescribing Opioids for Chronic
Pain | CDC Online Newsroom | CDC
CDC Advises Against Misapplication of the Guideline for Prescribing Opioids for Chronic Pain | CDC Online Newsroom | CDC
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