Oregon’s efforts to prevent opioid overdoses have reached a difficult impasse: what to do with the chronic pain patients who are on high doses of opioids now considered unsafe.
While some experts are warning about the potential harms of forcing stable pain patients off opioids, others insist reductions will benefit patients whether they want to make the change or not.
The divergence of opinion was on full display this week at the first meeting of a state task force convened to develop guidelines for tapering opioid use. It is the key issue to be resolved when a state commission meets Thursday to consider new chronic pain coverage rules for the Oregon Health Plan.
“I think the potential harms associated with opioids have become clear,” said Dr. Dana Hargunani, chief medical officer for the Oregon Health Authority. “Harms shown by the evidence about tapering are less clear.”
Both national and state prescribing guidelines urge judicious prescribing of opioid pain medication, generally limiting doses to less than 90 mg of a morphine-equivalent dose. But guidelines provide little guidance about whether patients above that threshold should be tapered.
In their opening remarks, many of the members of the tapering task force used terms like “compassionate” or “patient-centered” to express their preference that the guideline be implemented with flexibility, rather than in a draconian, one-size-fits-all manner.
Dr. Arian Nachat, a palliative care physician with Legacy Health, spoke about patients who sought out assisted suicide after being cut off of their opioids cold turkey.
“I hear this story happening more and more,” she said. “We can’t force people off opioids.”
But other members of the task force questioned whether the distinction between forced and unforced tapers was real.
“I can’t tell you whether the tapers I do in my practice are voluntary or involuntary,” said Dr. Roger Chou, a professor of medicine at Oregon Health & Science University and director of the Pacific Northwest Evidence-based Practice Center.
The majority of the time, patients don’t want to be tapered, he said.
“I explain why I think that’s important, that it’s a safety issue, and I guide them through the process. I try to be empathetic, but they don’t want to taper,” Chou said. “Is that voluntary or involuntary?”
Other members of the task force agreed, and said that if tapers were strictly voluntary, only about 25 percent of patients would ever be tapered. Chou also questioned whether the task force should use the terms patient-centered or compassionate.
“Compassionate sounds good but it’s a loaded term. At least in the discussion going on right now, it’s often meant to mean not tapering,” he said. “I don’t think there’s anything compassionate about leaving people on drugs that could potentially harm them.”
The task force plans to develop guidelines by the fall that any provider in the state could use in helping patients reduce their opioid use. While other health care organizations may endorse those guidelines, they will remain voluntary.
Thursday’s vote by the Health Evidence Review Commission on Medicaid coverage for certain chronic pain conditions, however, has a more direct impact on patients. The commission is considering a proposal to add coverage of five chronic pain conditions that previously had not been covered. The proposal would allow patients with those conditions to receive alternative services, such as acupuncture, yoga or physical therapy, in addition to opioid and non-opioid treatments.
An earlier version of the proposal would have required patients with those conditions to taper off opioids within a year. After significant public outcry and input from pain experts, the proposal was revised to allow at least some chronic pain patients to remain on opioids long term.
The revised proposal would still require patients with fibromyalgia or lower back pain, as well chronic pain patients who fail to meet the criteria for ongoing opioids, to be tapered off opioids altogether.
The proposed coverage change has garnered significant national attention. Chronic pain patients and pain experts from across the country fear it could set a precedent for other public and private health plans to force people off opioids.
More than 100 of the nation’s leading experts on pain and addiction medicine signed on to a letter penned by Dr. Sean Mackey, chief of pain medicine at Stanford University, urging the commission to put aside the proposal until more evidence was available.
“These requirements still mandate non-consensual forced tapering, which can cause grave destabilization to stable patients, without evidence of benefit,” Mackey wrote.
The letter said there were at least four comprehensive studies of opioid tapering that should be completed within the year and would provide a better understanding of the consequences of opioid tapers.
“We fear the HERC’s proposal is, in essence, a large-scale experiment on medically, psychologically and economically vulnerable Oregonians, at a moment when Oregon has already seen a significant reduction in opioid prescribing and prescription opioid-related deaths,” Mackey wrote. “The evidence supports that this proposal represents an alarming step backward in the delivery of patient-centered pain care for the state of Oregon.”
The proposal will be considered by a subcommittee Thursday morning and then by the full commission in the afternoon. If approved, the changes would go into effect in 2020. If the commission is not willing to proceed, it could table consideration, delaying implementation until 2022 at the earliest.
— Reporter: 541-633-2162, firstname.lastname@example.org