This is important for every Australian who is on long-term opioid therapy for chronic pain
Most people in the chronic pain community will not be aware that there are Draft Opioid Deprescribing Guidelines currently open for public comment. The Draft Guidelines and a template to comment are available at the link below.
If they become clinical guidelines in their current form then all chronic non-cancer pain patients can and will be involuntarily deprescribed, that is, force tapered off their opioid pain reliving medications.
If anyone wants to comment on the Opioid Deprescribing guidelines, these are the basic problems I find with them.
They were put together by mostly addiction medicine specialists and pharmacists, there is NOT one pain medicine doctor involved. These ‘experts’ by definition only see the 1% of chronic pain patients who become addicted to opioids, not the 99% who experience reduced pain and improved quality of life long-term. They are by definition biased against long term opioid therapy.
The consumer representative has a ‘health condition’ but there is no evidence that she has lived with either chronic pain or has experience with long term opioid therapy. She also happens to have a PhD in Pharmacology. She is another pharmacist! You cannot tell me that she is there in her capacity as a patient. I think it’s safe to say that NO consumer consultation has been undertaken.
They are putting hard limits on opioid prescribing and using 60-100MME as the ceiling. Anyone at or over this dose will be voluntarily, and possibly involuntarily DEPRESCRIBED. There is no place for hard ceilings in dosages or durations of opioid therapy because each person’s response to opioids is individual and based on their genetics and biology. With limits like these, many people will never experience proper pain relief for no reason other than their genetics. And many people who do experience good pain relief and improved quality of life with STILL be involuntarily deprescribed to a lower, likely ineffective dose, purely based on the dose! Further, 60-100MME is not considered a high dose by Cochrane reviews, the gold standard for medical evidence. 200MME is a high dose, therefore 60-100 would be a low to moderate dose.
These guidelines state that ‘occasionally’ it may be necessary to involuntarily deprescribe a person, if the doctor deems it so. This opens the door for GPs to deprescribe everyone with the guidelines backing them. At the moment, despite the fact that we know involuntary deprescribing is happening, these doctors are acting contrary to the current guidelines. The current prescribing guidelines explicitly state that patients should not be involuntarily deprescribed. That will not be the case if these guidelines are enacted as is. The gold standard will become deprescribing.
The guidelines say that where benefits are outweighed by adverse events, opioids should be deprescribed, but the recommendations clearly read that all patients on long term opioid therapy need to be deprescribed.
The first recommendation says that a deprescribing plan should be made on initiation of opioids, including time limits. And it states opioids should only be short-term. We know that some people do very well on opioids long term, they even quote studies that say so in these guidelines.
Involuntary deprescribing is associated with a high-risk of suicide and overdose, as stated in a study referenced by the guidelines, but they still say ‘occasional’ involuntary deprescribing is OK. They do not provide any guidance of when exactly involuntary deprescribing is OK (it should NEVER be ok) , therefore the guidelines are incomplete.
The guidelines also do NOT cover what to do if the person deconditions on deprescribing i.e. if their pain increases and their function decreases. It references taking a break in the taper, but then reinstating the taper. There is NO acknowledgement that some people require opioids long term. The guidelines are incomplete if there is no guidance on what to do when the patient has surpassed their lowest effective dose. What should happen is the lowest effective dose should be reinstated!
Remember, these guidelines are SUPPOSED TO BE for deprescribing where the benefits are outweighed by adverse events. If the patient is benefiting, they SHOULD NOT BE DEPRESCRIBED!
The guidelines say that attending the ER for pain or taking more pain medicine that prescribed are reasons to deprescribe. Taking extra doses or going to the ER are clear signs of undertreated pain and/or a pain flare NOT addiction. This should NOT be a reason to deprescribe!
The guidelines say that going to a different pharmacy or doctor than your usual one is a reason to deprescribe. Sometimes we need to go to a different pharmacy or see a different GP. I’ve seen a different GP when my usual doctor is on leave, for example. It’s also necessary to get a second opinion sometimes. If these guidelines become the clinical guidelines, seeing a different GP for a second opinion will be grounds for involuntarily deprescribing.
Involuntary deprescribing with become the Gold Standard treatment for all chronic non-cancer patients on long term opioid therapy. Good luck trying to convince any GP to prescribe long term opioid therapy once it becomes contrary to the gold standard guideline.
It’s very important we take this opportunity to have our say. They have a downloadable template to make it easy to submit comments.
This project has been in progress for over two years and has been open for public consultation for almost three months. Yet it can’t be found on google via any logical keyword search. I doubt many chronic pain patients have any idea that this is happening.
If anyone wants to comment, but doesn’t have time or energy to do so, I can help. Obviously, I’m not trying to put words in anyone’s mouth, if you don’t agree these are problems, that’s fine.
But in my opinion these guidelines will be disastrous for chronic non-cancer pain patients. They are doing all the things that the 2016 US CDC guidelines did, meanwhile the CDC has admitted they were wrong and are winding their guidelines back. We in Australia should not make the same mistakes the US made, we should learn from them.
Please consider sharing to your networks related to chronic pain. Cut and paste from this post if you like. Thank you.