The Anti-opioid Wheel Keeps Turning in Oregon (Part 1)-The Opioid Taper Task Force

By Wendy Sinclair

The past five years has been especially difficult for those suffering with intractable medical conditions that cause chronic pain. Even before the 2016 CDC guidelines, the social climate began turning against anyone who utilized opioid analgesics, whether for chronic pain or for addiction. Society seemed to make no distinction.

The climate allowed drastic policies and guidelines which limited or eliminated chronic opioid therapy for legacy patients (intractable pain patients benefiting from long-term opioid therapy). Because of this, many were harmed and some lost their lives to suicide.

Untreated or under treated pain has resulted in an increase in suicides. Rates among Veterans have shown a significant increase with chronic pain being one of the main contributors. And in Oregon, doctor assisted suicides have increased by 25% due to untreated pain. This is a far cry from the statement from 2007 stating that Oregon leads the nation in pain control for patients.

Well-respected experts, chronic pain patients, and advocates objected to the drastic paradigm shift and the significant harms asserting the swing was not based on evidence nor was it aligned with the standard of care or best practices. In the past year, nationally, the pendulum has begun to swing back to a neutral position giving suffers hope.

Some changes include:

1. In April of 2019, the CDC clarified their guidelines, stating that they had been misapplied resulting in forced opioid tapers and tapering too quickly which both caused patient harms. Their guidelines, which were only meant to aid primary care doctors in initial doses of opioid pain analgesics for opioid naïve patients, were misapplied to limit doses pain specialists could prescribe and restrict dosages for legacy patients.

2. April 9,2019, the Federal Drug Administration (FDA) issued a statement acknowledging harms (including suicide) from forced tapers. The FDA only gives instruction for opioid tapering when the taper is mutual agreed upon between patient and doctor.

3. April 24, 2019 Patrice Harris MD, President-elect of the American Medical Association (AMA) Opioid Task Force came out in support of legacy patients by releasing a statement applauding the CDC’s clarification of their guidelines stating they have been “widely” misapplied causing physicians to be unable to provide the best care to patients.

4. Humans rights watch (HRW), an international organization which reports on human rights violations, became involved with the opioid epidemic in response to the huge outcry of harm. After investigating, the HRW released a report supporting legacy patients and asserted there is an obligation to respond to this health need and to “refrain” from forced (non-consensual) opioid tapers. Furthermore, they state, “Under the ICESCR’s right to health framework, state parties have an obligation to ‘respect, protect, and fulfil’ the right of chronic non-cancer pain patients to appropriate pain management…”

5. Oregon’s geographical neighbor, Washington state has been doing damage control this past year from their previously released rules for opioids. They’ve issued statements and released documents stating that under-treating or refuse to treat pain is just as bad as over-treating. September 20, 2019 they released a letter as their latest attempt at reversing the damage.

In spite of all this, Oregon policy makers forge forward forcing many legacy patients to question their safety in the midst of known harms.

For over a year and a half advocates have vigilantly voiced concerns at the (previous) chronic pain task force meetings and now the taper task force meetings, through communication with the governor, her senior health policy advisor, testifying at the task force meetings, meeting with the chief medical officer of the Oregon Health Authority, and written comments from experts and patients. There has been one major request­, for evidence-based individual medical care based on each patients’ unique needs separating addicts from chronic pain patients and applying different remedies as is appropriate.

Here are just some of the efforts to curb Oregon’s anti-opioid stance:

1. The Human Rights Watch was specifically concerned about harmful policies/proposals/guidelines in Oregon so they wrote a personal letter to the Governor of Oregon, along with others, to object to the actions taken against legacy patients.

2. Oregon Medical Association and American Medical Association issued a letter opposing a proposal to force taper some patients off of their opioids.

3. Doctors and experts write a letter to the Oregon Governor Brown, and others, opposing a proposal that included some forced tapers and to request an evidence-based approach to pain care in Oregon.

However, these requests have fallen on deaf ears. They continue to lump addicts with legacy patients and offer a single remedy, or list of remedies. This is evident, once again, in the Taper Task Force meeting material. Not only is there only one taper protocol the decision to taper or “when to consider tapering” is the same irrespective of whether a person is utilizing opioids analgesics for pain or if they are using them for addiction.

Tapering is unidirectional regardless of the worsening of pain, which shows they acknowledge this guideline will affect those in pain, but there is no allowance to return a patient to their previously stable dose of pain analgesics.

The task force also attempts to broaden the inclusion of pain patients into the category of an addiction-type diagnosis by using only parts of the DSM5 in their diagnosis criteria for Opioid Use Disorder (OUD). They leave out the critical qualifier repeatedly asserted in the DSM5 that states, those using opioids “under appropriate medical supervision,” so compliant legacy patients cannot be diagnosed with OUD.

In addition, the guidelines seem to enlarge an addiction category to include many non-addicted legacy patients by the guideline’s criteria for Complex Persistent Opioid Dependence (CPOD). The difference between OUD and CPOD are startling. To be diagnosed with CPOD one only has to have the desire to take opioids for pain, without opioid cravings, no compulsive use, and no harmful use, the patient takes opioids “exactly” as prescribed, and has no social disruption other than from experiencing pain. This is an incredible description and includes all model chronic pain patients.

Amidst pressure from advocates and patients, Oregon’s Taper Task Force have added a clarifying statement to their updated materials, stating not all patients need to be tapered, but then the rest of the guideline goes on to recommend providers consider a taper for those who meet certain criteria, that is easily met by the majority of legacy patients. Such as:

· The patient is on a daily opioid dose of 50–90 MED or higher.

· The patient has medical risk factors that can increase risk of adverse outcomes. including overdose (e.g., lung disease, sleep apnea, liver disease, renal disease, fall risk, medical frailty).

· The patient is taking other medications that increase the risk of drug-drug interactions or the risk of overdose, such as benzodiazepines or other sedating medications (e.g., Benadryl, Gabapentin).

· The patient’s history indicates an increased risk for substance use disorder (SUD) (e.g., past diagnosis of SUD, SUD-related behaviors, family history of SUD).

To put this in other words, the majority of legacy patients are on 50 MED or higher, so that one criterion alone encompasses a huge percentage of patients. In addition, the rest of the criteria includes advanced age (medical fragility- the term they use to describe older people), people who have allergies (take Benadryl) people who have anxiety disorders or need awake oral surgery or any other twilight surgery (benzodiazepine), those who have nerve pain (Gabapentin), and those who don’t have SUD, but who have a family member who has it (have an uncle who has SUD, even though you don’t). After including all these, there will be few legacy patients who won’t fall within the recommendation to consider tapering.

Why is the narrative the same when other states and nationally there’s been some movement?

· The task force membership includes a large percentage of addiction specialist who are allowed to make policy for chronic pain patients even though they do not have specific knowledge on this population.

· The task forces membership doesn’t include non-addict legacy patient representatives

· The task force recycles many of the same members or representatives from the same organization over and over

· addicts and legacy patients are lumped together and given the same guidelines

· The public commenting process is often confusing and not transparent

· There’s been no collection of data on patient harms for current forced taper policies (Back and Spine Guideline Note 60), but claim success based solely on the fact that the patients were tapered. Despite agreeing to revisit the guideline this fall, we have yet to see a plan to do so.

Despite the evidence and efforts to the contrary, Oregon doesn’t seem to be curbing their anti-opioid sentiment even with the knowledge that it will cause patient harms.

The taper task force guidelines will be enforced for all Oregonians regardless of insurance (Medicaid, private, or self-pay). Oregon is a scary place for legacy patients.