Opioids and chronic pain - in all of medicine only chronic pain is treated this way

And it makes absolutely no sense.

Imagine this: a patient, lets call her Sue, has severe depression. She presents to her doctor. She is referred to a psychologist, and her GP immediately starts anti-depressant medication. Sue is advised to come back in four weeks, to review. Which she does.

She’s not doing better, so the dose is increased. Sue is reviewed two more times over the next eight weeks, each time her dose is increased, and at that point, she is feeling better.

The medication is working, she feels. The darkness has lifted, the black dog has been banished. She is grateful to her GP. She is still waiting on a psychological appointment, as psychologists are very hard to find. And expensive.

The GP is very happy though, because the medication is working well. It has taken many weeks, but the GP has titrated the dose upwards, to find the minimum, effective dose that controls Sue’s depression.

Sue comes back in another four weeks. She is happy, back at work, and socialising again. Life is good!

Her GP now tells her that its time to taper the anti-depressants.

Wait, what?

Or how about this: Sue has high blood pressure. She is at her GP for her yearly physical and her hypertension is discovered during basic physical exam. Her GP prescribes anti-hypertensive medication and advises Sue to return in two weeks for review. At this review, her blood pressure is still high, so the dose is increased. Sue has two more dose increases, and then her blood pressure is beautifully in the normal range. She is experiencing no side effects and is very happy with the treatment. When she returns at her 12-week review, with perfect blood pressure, her GP is very pleased. And he then tells her ‘your blood pressure is now perfect. Its time to taper you off the medication’.

Or how about high cholesterol? Or high blood sugar? Or asthma? Epilepsy maybe?

I think you get see where I am going with this.

This would never happen.

Because it’s ludicrous; It makes no sense, medically or otherwise.

The medication is causing the improvement, the improvement will reverse if the medication is taken away. That’s only logical. And that’s why it is NOT done. In these situations, people are generally advised that they need to be on these medications for life, or their health will deteriorate.

Where, in medicine, do doctors titrate the dose of a medication to a point where the symptoms/complaint is well managed, the patient is doing well, is happier and healthier and doing well, AND THEN TAPER THE PATIENT OFF THE MEDICATION?

And somehow the doctor expects the positive effect to continue, that the patient will remain well, even though the medication that caused the improvement has been taken away? Without any alternative therapy to replace it?

How does that logic even work?

Where does this happen?

Only in long term opioid therapy for chronic pain.

Doctors will prescribe a trial of opioid pain medication, which proves to be safe and effective for the patient. The patient reports well controlled pain, no significant side effects, they are back at work, socialising, living life again.

Success!!!

AND THEN THE DOCTOR TAPERS THE MEDICATION. Generally by force. Against the patients wishes.

And the doctor expects the patient to remain doing well!!??!!

Without the medication.

Utter insanity.

Not evidence-based medicine. There is no evidence to support this practice.

I know what the theory is, what doctors have been taught. But it’s not realistic. And not evidence based. Yet doctors don’t question it.

The idea is that, in the meantime, the person has learned about pain with pain science education, is doing physiotherapy and has started to exercise, is seeing a psychologist, has worked on their sleep hygiene and their nutrition. And now their pain has been reduced by these other modalities.

Except these other modalities will do NOTHING for severe, disabling, pathological, secondary pain.

Please point me to one study that shows that improving sleep will reduce the pain of MS or CIDP or Parkinson’s. Or one study that shows that CBT or ACT or mindfulness will reduce the pain of RA or Lupus or AS.

These things may be helpful in very small ways for severe, disabling, chronic secondary pain. Their effect has been vastly overstated in chronic secondary pain.

Lifestyle modification CAN have a large impact on a person who has mild to moderate chronic primary pain. Primary pain being pain that does not have a pathological cause. Its psychological pain, therefore psychological treatments may be effective.

But its completely ineffective for pathological chronic pain.

People will feel great while on their opioid, and they can start exercising again. They can restart their hobbies, and socialising and ofcourse work. They feel better mentally, are happier. Life is great again.

But there is no magic there. Those things, the working, the socialising the exercising, the improved mental health, they are BECAUE THE PAIN IS NOW WELL TREATED.

Take the pain management away, the pain returns. The career disappears, the social life disappears, depression returns. Exercise is impossible while in severe pain. Everything returns to terrible.

There is no magic trick. The pain does not magically go away! There is NO ALTERNATIVE TO OPIOIDS FOR SEVERE PAIN.

Maybe one day there will be, but for now? No. There is nothing that will touch severe pain, be it acute or chronic.

And so, for doctors to provide a trial of opioids, with the goal of tapering those opioids from the start, is insanity.

The only reason opioids should be tapered is if there are intolerable side effects, if they are not effective for the pain, or the PERSON wants to taper.

Those are the ONLY reason to taper.

NO one should be force tapered. Ever.

Force tapering leads to pain crisis, suicidal ideation, overdose and death. That’s what the science says.

Opioids are safe and effective long term, for a select minority of people – those who live with severe, disabling pain due to incurable disease or injury.

Think about how cruel it is t provide the solution, to give a person their life back…and then TAKE IT AWAY again.

Its abhorrent.

Its barbaric.

Its not medicine. It’s not science. Its not human.