For some patients who have been doing well on opioids long-term, it makes sense to “leave well enough alone,” the doctor said.
Today, much of the medical community is focused on reducing opioid prescriptions after decades of overprescribing, but one doctor is an outspoken critic of weaning patients who are doing well on long-term or high-dose opioid prescriptions.
Dr. Stefan Kertesz, a primary care physician who focuses on addiction medicine and works with the homeless population, told STAT News that he is challenging the idea that even people who are doing well on opioids need to have their medications reduced or replaced.
“I think I’m particularly provoked by situations where harm is done in the name of helping,” said Kertesz, who is also a professor at the University of Alabama at Birmingham School of Medicine. “What really gets me is when responsible parties say we will protect you, and then they call upon us to harm people.”
In particular, Kertesz takes issue with the CDC’s 2016 opioids prescription guidelines. The guidelines were interpreted very strictly, and have led to many pain patients—even those who have not abused their medications—seeing their care regimen change.
For some patients who have been doing well on opioids long-term, it makes sense to “leave well enough alone,” Kertesz said.
He believes that the general recommendation to be careful when prescribing opioids is sound advice. However, when the recommendations are taken as a mandate, problems can arise, he said in a written response to the guideline.
“This is a guideline like no other… its guidance will affect the immediate well-being of millions of Americans with chronic pain,” Kertesz wrote.
In another written response he said, “Most of us wish to see an evolution toward fewer opioid starts and fewer patients at high doses,” but doctors need to be able to leave some patients on opioids as clinically necessary without feeling like they are putting their careers at risk.
Kertesz encouraged the CDC to clarify that the guidelines were recommendations only, not policy proclamations.
“It is imperative that healthcare professionals and administrators realize that the Guideline does not endorse mandated involuntary dose reduction or discontinuation,” he wrote in one letter that he co-authored. “Patients have endured not only unnecessary suffering, but some have turned to suicide or illicit substance use.”
Now, Kertesz is hoping to secure funding to study suicides caused by reduction in pain medications.
“You have three things that are potentially simultaneously associated with harm: Pain itself. Opioid dependence, the dependence itself. And the event, however we wish to interpret it clinically—as resurgent pain or untreated opioid dependence—in patients who are having opioids taken away,” he explained.
Despite his dedication to speaking out against uniform opioid reductions, Kertesz sometimes still feels nervous about standing against the mainstream medical community.
“Every single bit of it involves ambivalence and driving myself crazy,” he said. “Like, am I making a mistake? Am I going to blow up my career?”