Thread by @JillPiggott

2017 Review: “Expert guidelines recommend reducing or discontinuing long-term #opioid therapy when risks outweigh benefits, but evidence on the effect of dose reduction on patient outcomes has not been systematically reviewed.” / #cpp thread.

🟠 How can guidelines be "expert" recommendations if researchers haven't carefully investigated how patients will react when their rx #opiod med is stopped or reduced?

Are we going to feel better or worse? Are we going to live or die?

In 2017, #VA-funded researchers identified 67 studies about #opioid dosage reduction or discontinuation.

Study quality was deemed “poor” in 76% of the 67, the lowest rating.

Overall quality of evidence was "very low" for all 6 patient outcomes: pain severity, pain-related function, quality of life, opioid withdrawal symptoms, substance use, or adverse events. "Adverse events" include #overdose & #suicide.

#Gratitude: @josephwfrank My colleague Dr @NitaGhei & I direct @headsUPmigraine. Thanks to you & your 2017 team for your review. It's fuel for our advocacy.

#Outrage: #CDC should have investigated outcomes before releasing the Guideline.

States, insurers, physicians, practices, hospitals, & policymakers should have demanded evidence about patient outcomes before mandating or even recommending #opioid discontinuation or reductions.

People are DEAD because widespread rx #opioid reductions went forward without a review of outcomes.

People are DYING now because the policy continues, despite widespread evidence of unnecessary disability, distress, disease progression, & death. #FDA cited these harms in 2019.

VA-funded researchers tracked what happened to the #vets whose rx #opioid was stopped in FY 2013. They found 2,887 #veterans dead from overdose or suicide.

1 year of discontinuation at the VA produced just 90 fewer bodies than terrorists did on 9/11. bmj.com/content/368/bm…

Just this morning, I learned a fellow #cpp advocate's dad recently shot himself because he couldn't find a doctor to prescribe effective pain medicine.

That's not "poor coping." Severe & chronic #pain puts us at up to 6 x the risk of #suicide even without depression.

Discontinuing & reducing #opioids increases the risk of #suicide by as much as 6.8 times (see Oliva above). But failing to prescribe effective #opioid pain med can put people in pain at high risk, too. researchgate.net/profile/Richar…

#Pain, #suicide, #opioid discontinuation

#PrimaryCare #PCP #neurology #MedicalTwitter
suicideinfo.ca/wp-content/upl…

24.85% w/ acute pain (AP) & 34.9% w/ #ChronicPain (CP) reported a history of wanting to die.

5.83% of people w/ AP & 9.38% w/ CP reported frequent active #suicidal ideation, nearly 2x - 3x the risk of people w/o pain.
academic.oup.com/painmedicine/a…

7.06% w/ acute #pain & 7.92% w/ #chronicpain reported having a #suicide plan (4.3 to 4.8 x risk in people w/o pain).

14.11% w/ AP & 20.53% (CP)--1/5th--had attempted suicide (2.2 to 3.25 x risk of people w/o pain).

Depression & insomnia increase this risk dramatically.

We have enough evidence RIGHT NOW to know rx #opioid reductions INCREASE the risk of death (overdose & suicide) & are (obviously) ineffective at stemming the terrible crisis of overdoses to illegal drugs.

There's no excuse. Stop. #Enough.

@headsUPmigraine @NitaGhei
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🚩 UPDATE. A 2019 paper discusses the findings of a panel that met to discuss the challenges of implementing the CDC Rx #Opioid Guideline. Here's how the 2017 Review ("very-low quality" evidence on all 6 patient outcomes) is summarized in the 2019 paper. (Hold onto your hats.)

"A recent systematic review found low-quality
but consistent evidence suggesting that several types of
#opioid tapers may be effective & that pain, function,
& QOL may improve for some patients w/
consensual opioid dose reduction, esp w/ the
support of a multidisciplinary team."

'17: There's "very-low-quality evidence that opioid dose reduction may improve pain, function, & QOL."
'19: Altho gradual/supported "taper are believed to be associated with improved pain outcomes, the evidence base on #opioid dose reduction & discontinuation is still
evolving."

People who BELIEVE tapers improve pain can know they're looking at "very-low-quality evidence" & see it as "evolving."

This BELIEF is the single biggest impediment to letting doctors prescribe #opioids the way they prescribe all other meds: to individuals, based on evidence.

Kroenke K, Alford DP, et al. Challenges with implementing the centers for disease control and prevention opioid guideline: a consensus panel report. Pain Medicine. 2019 Apr 1;20(4):724-35.academic.oup.com/painmedicine/a…

@NitaGhei @headsUPmigraine If I weren't a disabled footnote junkie, I wouldn't have noticed this. How many primary-care physicians have the time to sit around matching a summary in 1 paper to the original text?

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