Forced Tapering: Only Chronic Pain Patients Are Treated This Way
/By Neen Monty
Imagine this: A patient, let’s call her Sue, has severe depression. Her GP prescribes an anti-depressant and refers her to a psychologist. Sue is advised to come back in four weeks. Which she does.
She’s not doing better, so the dose is increased. Sue is reviewed two more times over the next eight weeks, and each time her dose is increased.
Sue starts feeling better. The medication is working. The darkness has lifted, the black dog has been banished. She is grateful to her GP.
The GP is also happy. It has taken many weeks, but the GP raised the dose 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!
That’s when the GP tells her that it’s 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 the hypertension is discovered. The doctor prescribes a blood pressure medication and advises Sue to return in two weeks. At this review, her blood pressure is still too high, so the dose is increased.
Sue has two more dose increases, and her blood pressure falls into the normal range. She is experiencing no side effects and is very happy with the treatment.
When Sue sees her GP again with perfect blood pressure, he is pleased. Then he tells her it’s time to taper off the medication.
What if Sue had high cholesterol? Or high blood sugar? Or asthma? Epilepsy maybe?
I think you see where I am going with this.
The tapering would never happen, because it’s ludicrous and makes no sense, medically or otherwise. In these situations, people like Sue are often advised that they need to be on a medication for rest of their lives.
Where in medicine do doctors increase the dose of a medication until the symptoms are well managed and the patient is doing better -- and then gets tapered?
Only when the patient has chronic pain and is on opioid therapy. Doctors will prescribe a trial of opioids, which prove to be effective. The patient reports well-controlled pain, no significant side effects, and they are back at work, socialising, and living life again.
And then the doctor starts tapering the opioids. Against the patient’s wishes.
Utter insanity.
That’s not “evidence-based medicine.” There is no evidence to support this practice. I know what the theory is, and what doctors have been taught. But it’s not realistic. Yet many doctors don’t question it.
The theory is that once a patient gets pain relief, they will learn how to manage it without opioids. They’ll start to exercise and meditate, see a psychologist, work on their sleep hygiene, and get proper nutrition.
Except these other modalities will do nothing for severe, disabling pain.
Please point me to one study that shows that improving sleep will reduce the pain of multiple sclerosis, chronic inflammatory demyelinating polyneuropathy, or Parkinson’s disease. Or one study that shows cognitive behavioral therapy or mindfulness will reduce the pain of rheumatoid arthritis and lupus.
Those treatments may be helpful in very small ways. But their effect has been vastly overstated for chronic secondary pain -- pain that is caused by an injury, tissue damage, or disease.
Lifestyle modification can have an impact on a person who has mild to moderate primary pain -- chronic pain that does not have a known pathological cause. That pain is sometimes driven by emotional or psychological causes, so psychological treatments might be effective.
But they are ineffective for chronic secondary pain.
People will feel better on opioids, but its not “euphoria.” It’s because they can start exercising again, restart their hobbies, and return to work. They’ll feel happy again. Those positive things happen because their pain is now being treated.
Take away the pain medication, and the pain will return. The career grinds to a halt, the social life disappears, depression returns. Exercise is impossible while in severe pain. Everything returns to terrible.
There is no magic trick that can replace opioids. There is nothing else that will touch severe pain, be it acute or chronic.
And so, for doctors to provide a trial of opioids for secondary pain with the goal of eventually tapering patients 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 patient wants to taper.
No one should be forcibly tapered. Ever. Forced tapering leads to a pain crisis, suicidal ideation, overdose and death. That’s what the science says.
Opioids are safe and effective when taken long term by a select minority of people – those who live with severe, disabling pain due to an incurable disease or injury.
Think about how cruel it is to provide them with a solution to their pain, to give them their life back, and then take it away.
Its abhorrent.
Its barbaric.
It’s not medicine. It’s not science. It’s not human.
Neen Monty is a writer and patient advocate in Australia who is dedicated to challenging misinformation about pain management. Drawing on lived experience and scientific research, Neen has created a website for Pain Patient Advocacy Australia that is full of evidence that opioids can be safe and effective, even when taken long term. You can also subscribe to her free newsletter on Substack, “Arthritic Chick on Chronic Pain.”
