Thread by @TNREthx

Very happy for this paper to be out in the world. In it, I argue that non consensual discontinuation of opioid therapy for stable legacy patients is wrong. This is true even if it means prescribing opioids for a patient indefinitely.

Argument preview:

journalofethics.ama-assn.org/article/noncon…

1. Holding that reducing overprescribing entails forced deprescribing overlooks the difference between initiating and continuing opioid therapy.
2. Physical dependence changes the risk-benefit profile of opioids, as the harms of withdrawal and increased pain must be considered.

3. Lastly, the fact that the medical establishment put legacy patients into their current predicament should count in favor of patients being given a voice in their care. Having made patients vulnerable, they deserve a say in how that vulnerability is resolved.

Importantly, I argue that such prescribing is not ‘misprescribing’, and so not legally prohibited. It follows the best legal and ethical guidance concerning care for one’s patients.

Practically, if the clinician thinks that a taper would be best for the patient, they should counsel the patient in that direction, providing reasons and making clear the supports available. But if the patient never comes around, the clinician should continue prescribing.

Of course, this is for ‘stable’ patients; inability to control pain, escalating dose, signs of a developing OUD, all should be treated in partnership with relevant experts who work to make the patient as safe as possible. But in no case is abandoning the patient permissible.

I’ve talked to hundreds of docs struggling with cases like this, and there is a lot of avoidable tragedy as a result of pressure to abruptly stop prescribing. I believe the arguments make clear that forcibly tapering (or esp abandoning) patients is wrong. Norms must change.

My deep gratitude to @StefanKertesz for discussing this paper with me extensively, and to @dineenkk for help with the legal analysis. I’m also grateful to my mentee, Dr. Hunter Smith, for editing such an important issue, and the @JournalofEthics for publishing it!