Nonconsensual Dose Reduction Mandates are Not Justified Clinically or Ethically: An Analysis

Abstract

<jats:p> This manuscript describes the institutional and clinical considerations that apply to the question of whether to mandate opioid dose reduction in patients who have received opioids long-term. It describes how a calamitous rise in addiction and overdose involving opioids has both led to a clinical recalibration by healthcare providers, and to strong incentives favoring forcible opioid reduction by policy making agencies. Neither the 2016 Guideline issued by the Centers for Disease Control and Prevention nor clinical evidence can justify or promote such policies as safe or effective. </jats:p>

Factors Associated with Pain Treatment Satisfaction Among Patients with Chronic Non-Cancer Pain and Substance Use

“…However, this finding aligns with growing concerns with consequences of discontinuing opioid therapy in patients with CNCP, especially in those with substance use. 46,47 Despite a lack of evidence supporting long-term opioid efficacy in CNCP treatment and some evidence suggesting improved pain scores with opioid tapering, 48,49 recent studies have cited potential harms of opioid discontinuations, including increased suicidal ideation from uncontrolled pain, return or initiation of illicit drug use leading to increased overdose risk and death, and increased emergency department visits and hospitalizations from adverse health events. [50][51][52][53][54][55][56] While we do not know whether participants consented to opioid discontinuations, mounting pressure from regulators to curb opioid prescriptions suggests many were likely provider-directed.…”

<p>The Repeal of the Affordable Care Act and Its Likely Impact on Chronic Pain Patients: “Have You No Shame?”</p>

“…In summary, all Americans will be adversely affected should the ACA be repealed. Those who are most vulnerable are likely to be punished most severely should the administration be successful in striking down a program that protects Americans' health and well-being, and the approximately 50 million American citizens with chronic pain are extremely vulnerable, 51,52 to say the least. According to a 2018 article by Stein and Allcorn, President Trump's efforts to repeal the ACA do not represent sound public policy, but rather reflect his narcissistic and racially-driven hatred of President Barack Obama.…”

Is Nonconsensual Tapering of High-Dose Opioid Therapy Justifiable?

“…Physicians like Dr G presumably believe that high-dose opioid therapy carries significant risks and thus that reducing or eliminating opioid use is indicated. Although the evidence is not actually clear on this point, 8 I will assume that Dr G is correct that a reduced dose might be better for Mr T from a clinical standpoint for the sake of exploring whether nonconsensually reducing Mr T's dose is ethically justifiable.…”

“…The fact of physical dependence changes the risk-benefit profile of opioid therapy. 8 Mr T fears the withdrawal symptoms that come with discontinuing opioids, and this fear is a perfectly reasonable one: withdrawal can be far more than unpleasant or painful; it can be an absolute nightmare. 9 And because a patient who has been on chronic opioid therapy might know the symptoms of withdrawal well, the prospect of withdrawal itself can cause significant anxiety.…”