"The policy response to the opioid epidemic http is frequently framed as a conflict If you pull back the opioid painkillers that led to the epidemic you are going to harm the pain patients who use these opioids to treat their pain. In effect youre trading one problem addiction for another undertreatment of chronic pain. A new study httpannals.orgaimarticlepatientoutcomesdosereductiondiscontinuationlongtermopioidtherapysystematic published in the Annals of Internal Medicine however offers a cause for optimism Reviewing the research so far it found that it may be possible to reduce doses for patients in longterm opioid therapy and improve their pain outcomes. So doctors can potentially pull back the opioids that launched the current drug overdose crisis and still successfully treat pain patients. Now by this latest studys own admission the evidence is of generally poor quality. Most of the studies reviewed were of poor methodology or sample size while only a few were of fair or good quality. The review also only looked at patients who volunteered to taper off opioids meaning this research does not prove that involuntarily pulling patients off the drugs will lead to similar outcomes. Suffice to say then a lot more research is necessary before this issue is settled. But the new study does offer a glimmer of hope in a fairly grim opioid epidemic Maybe it is possible to reduce the amount of dangerous opioids that patients are consuming and still alleviate peoples pain. What the study found For the latest review of the evidence researchers looked at  studies that collectively provided data on more than  pain patients who were weaned off at least some opioids. Though the researchers found a lot of studies to pool from they generally graded these studies as very low in quality and methodology.  Researchers then identified the studies  none of which were graded as good quality  that evaluated painrelated outcomes for patients after longterm opioid therapy was tapered. Focusing on the fairquality studies they found that after opioid dose reductions patients on average saw improved pain function and quality of life. The authors provide a few possible explanations for this Perhaps the nonopioid pain treatments such as physical therapy and meditation that accompanied dose reductions simply produced better results than the opioids did. Maybe the opioids themselves caused problems that negatively impacted function or quality of life such as constipation fatigue poor sleep and depressed mood. Its possible that opioid dose reduction also resolved whats known as opioidinduced hyperalgesia a paradoxical response in which patients receiving opioids become more sensitive to painful stimuli. Or the researchers suggested the observational studies simply showed reverse causation  that is patients successfully tapered opioids because pain severity decreased. The findings do not mean that doctors can now simply yank patients off opioids and expect them to get better. For one the reviewed studies generally looked at the results of tapering when patients are slowly weaned off opioid painkillers  a process that Stanford psychiatrist Anna Lembke told me https can take months or even years.  Crucially the studies also looked at what happened when these reductions in opioid doses were paired with alternative treatments including alternative medicines like acupuncture interdisciplinary pain programs and medicationassisted treatment for addiction. This is very very different from a situation in which a patient is taken off opioids and effectively left stranded without any other form of care. As the researchers readily admit the study also had several major limitations. Most of the studies analyzed were of poor quality  meaning theres a serious need for better research in this area. And the studies only evaluated voluntary reductions in opioid doses its entirely possible that involuntary reductions in opioid doses would lead to sharply different outcomes. We should be cautious in interpreting the findings Joseph Frank lead author of the study told me. He emphasized that more research needs to be done to fill important gaps in our knowledge. He added I want patients and their doctors to use caution in applying this. A few pain patients will still benefit from opioids One of the studys implications is that opioids actually arent a good treatment for chronic pain. This isnt new. As the Centers for Disease Control and Prevention concluded http in its  summary of the research there are simply no good longterm studies looking at the effects of opioids on longterm pain outcomes while there are many studies showing that longterm opioid use can lead to bad results in other areas including addiction and overdose. That does not mean opioids are never an effective treatment for chronic pain.  As addiction and pain experts often tell me health care can vary vastly from patient to patient. Some patients feel worse on opioids while others report quick pain relief. Some patients experience grueling withdrawal if taken off opioids while for others the symptoms are much less severe. Some patients are at unusually high risk for addiction while many  most in fact  arent. And so on. In a few cases then opioids will still be the best answer for some individual chronic pain patients. When prescribed carefully on a schedule that works to diminish the excessive buildup of tolerance they can work for some people. But as Stanford pain specialist Sean Mackey emphasized to me https opioids should not be a firstline treatment due to the risks and alternatives should be tried first. This then is another key caveat to the study Its findings shouldnt be applied to every patient. Like much of health care each case will typically require individual evaluations to see what works. There are people who do well with tapering opioids Stefan Kertesz an addiction researcher at the University of Alabama Birmingham who was not involved in the study told me. There are people who do not do well with tapering. But the study suggests that getting some patients off opioids could improve their pain outcomes. The key is convincing patients that this truly can work so they buy into the treatment and genuinely follow through with it  and making nonopioid treatments for pain accessible enough that patients see them as realistic options. Alternative pain treatments need to be made more accessible The reality though is nonopioid pain treatments are often out of reach for many Americans. Patients may not have insurance to cover the treatment. Even if they do have insurance their health plan might not cover comprehensive pain care. And even if they do have insurance and their health plan covers pain treatments there may not  particularly in rural areas  be a nearby pain clinic or doctor who can actually provide the care these patients are seeking.  This is something the studys authors readily acknowledge. Its an important part of this challenge Frank said. These nonopioid strategies that were tested in these research studies are not adequately available. Several of the studies were done in pain centers where they have expert programs and those just are not widespread. In fact the lack of access to nonopioid strategies may be one big reason that doctors resorted to opioids in the first place. The drugs offered an easy answer  if ultimately an ineffective one  to the many problems doctors faced including patients who had complicated pain problems that physicians didnt fully understand and tight schedules driven by the current demands of the health care system that made it hard to take the time to work through a patients individual problems. More on all that in my interview with Lembke http To address this Frank argued that patients need better access to pain treatments. And doctors especially primary care doctors who are frequently the first people patients see in the health care system also need to be better trained to deal with chronic pain. These solutions could help a lot of people According to one study http from the Institute of Medicine  million US adults suffer from chronic pain. The opioid epidemic shows that if this care isnt made available patients may end up resorting to drugs that can literally get them killed  or as has been reported httpsoup.silverchaircdn.comoupbackfileContent_publicJournalpainmedicine.pme..pdfExpiresSignatureBoOUYyZhOCUNKFwJKedZoKdgzGBDhlWZycrQCyjbWVigBononmpNtSsvnxqzOfoFyfcxrfemdReYYCvGpuHXRnXnRWKyzQzEDfNBvaqpdHMZirvyEtJSWQzdTZSVFHjtwQHNsOgOkfAvXmqHMMgaBztYcDymCUemQkMWucGUiZPZssvDaNCSupibyEJzJsDvkiIHFnxGHXcveqARTvQWPDvZUZBSgfyBoZSTwWHFmLMjesPGivMbOXKvTLbxvrfCHDJByhoACUDw__KeyPairIdAPKAIUCZBIALVPAVWQ in other tragic cases http they may kill themselves once the pain grows too bad. The newest study however noted that there is no good research yet looking at these two potential outcomes if pain patients are taken off opioids. Not only do we lack the data but I have seen and heard of countless cases of overdose and suicide from people who have been involuntarily discontinued Kertesz said emphasizing this is strictly based on anecdotal observations. One day in June in my inbox were  deaths. Opioid policy is a balancing act The findings show the balancing act of opioid policy Even if doctors need to pull back opioids they must be careful to ensure patients suffering from debilitating pain and other problems can still meet their other care needs. Its not just pain care. When dealing with opioid users who are addicted doctors and policymakers also need to ensure that addiction treatment is available. Otherwise these patients will likely try to find another source of drugs  even if it means resorting to a riskier opioid such as heroin or fentanyl https to satisfy their cravings. Theres good evidence this happened to many  but not all  opioid painkiller users A  study httparchpsyc.jamanetwork.comarticle.aspxarticleid in JAMA Psychiatry found  percent of heroin users in treatment started with painkillers and a  analysis http by the CDC found people who are addicted to painkillers are  times more likely to be addicted to heroin. The fundamental problem is many of these patients dont get addiction treatment once they lose access to painkillers or before they progress to heroin or fentanyl. Without the option of treatment opioid users only answer to averting dependenceinduced withdrawal becomes harder drugs. Yet based on a  report httpsaddiction.surgeongeneral.gov by the surgeon general only  percent of Americans with drug use disorders get specialty treatment. That doesnt mean that reducing prescriptions is a mistake. By stopping doctors from unscrupulously prescribing the drugs governments can potentially stop opioids from flowing to new users who didnt really need the drugs and could have developed addictions had they been allowed to get painkillers.  But the reduction has to be paired with increased access to addiction care  and it frequently hasnt been. Beyond addiction treatment Kertesz argued that policymakers should also address some of the underlying conditions that drive addiction. He emphasized the need for broader mental health care given that people often have mental health issues that can make addiction more likely. Who is at higher risk  John with PTSD and a dose of  milligrams a day or James who has no PTSD and is on  milligrams a day Kertesz said. Based on his reading of the data its John with PTSD on the  milligrams. But as is true for addiction and pain treatments adequate mental health care is also out of reach for many patients  showing just another way that the US health care system isnt built to adequately address the full needs of patients. All of this shows why the policy solution to the opioid epidemic isnt as easy as simply pulling back prescription opioids To avoid exacerbating existing problems or causing new ones policymakers need to consider the other needs of people who were perhaps getting opioids they didnt really need."