International medical experts warn in an open letter to health authorities that forcing patients off opioid painkillers could sometimes do more harm than good. The letter, published in the journal Pain Medicine, outlines risks associated with forced tapering of the addictive drugs and petitions U.S. policymakers to develop guidelines that are not “aggressive and unrealistic.”

The U.S. Centers for Disease Control and Prevention advocates tapering and, in some cases, discontinuing opioids in patients using them as long-term therapy for chronic pain.

However, in their letter, Beth Darnall of Stanford University in California and coauthors say mandated opioid tapers requiring “aggressive” dose reductions over a defined period, even when that period is an extended one, could be problematic.

“Opioid tapering guidelines were created, in part, to decrease harm to patients resulting from high-dose opioid therapy for chronic pain. However, countless “legacy patients” with chronic pain who were progressively escalated to high opioid doses, often over many years, now face additional and very serious risks resulting from rapid tapering or related policies that mandate extreme dose reductions that are aggressive and unrealistic.”

“Rapid forced tapering can destabilize these patients, precipitating severe opioid withdrawal accompanied by worsening pain and profound loss of function.”

The authors call for “compassionate systems for opioid tapering” in carefully selected patients, with close monitoring and realistic goals. They also call for “patient advisory boards . . . to ensure that patient-centered systems are developed and patient rights are protected.”

“The assumption that forced opioid taper is reliably beneficial is not supported by evidence, and clinical experience suggests significant harm,” said Ajay Manhapra of Yale University, who co-authored the letter.

For example, the letter notes, rapid forced tapering can destabilize patients, lead to a worsening of pain, precipitate severe opioid withdrawal symptoms and cause a profound loss of function. Some patients may seek relief by sourcing illicit, and more dangerous, opioids, while others risk becoming “acutely suicidal”, the paper adds.

Patients on legacy opioid prescriptions require different considerations and careful attention to the methods by which opioid tapers might be considered and implemented.

Currently, no data exist to support forced, community-based opioid tapering to drastically low levels without exposing patients to potentially life-threatening harms.

Existing data that support rapid reductions of opioid doses – often to zero – were conducted in highly structured, supportive, interdisciplinary, inpatient settings or “detox” programs in which medications and other approaches were used to minimize the symptoms of withdrawal. These data do not inform community-based opioid tapering. Currently, nonconsensual tapering policies are being enacted throughout the country without careful systems that attend to patient safety. The methods by which a taper is conducted matter greatly.

The letter petitions the U.S. Department of Health and Human Services to consider patient data and include pain specialists when developing opioid tapering guidelines.

Manhapra believes the onus remains on policymakers. “It appears that the storm blew one way from 1980’s to 2016 and now it is blowing hard the other way, while we (doctors) stand staggering at the same spot trying to take care of our patients who are suffering,” he said.