Who arrives, and how they got here

Patients who arrive at this practice on an opioid average more than 90 morphine milligram equivalents a day. They have usually been in pain for two and a half years or longer. Practice-reported figures from our own population, not trial outcomes, and individual results vary. Almost none of them went looking for the drug. They went to a clinic with a back that hurt. The clinic had a scan and a prescription pad and no diagnostic block. The prescription was renewed every month by a system that bills a renewal faster than it bills an exam. Then the taper mandates arrived. The same system that created the dependence began discharging the people it had created. A steelworker from Granite City found himself on his fourth clinic with a dose nobody wanted to own. Dr. Gurpreet Singh Padda, MD, MBA, MHP calls what happens next harm reduction for people in real bodies with real jobs. It is not a policy enforced with a clipboard. The enemy on this page is an incentive. It is never the patient.

Why not just stop the opioid first?

Three things are true at once in a patient on a long-term opioid. First, the structure that started the pain is still firing, because a drug that dulls a signal does not repair a joint. Second, the nervous system has adapted. Tolerance means the same dose does less. And opioid-induced hyperalgesia (pain made worse by the drug) is documented across the animal and human studies in the pain-medicine reviews. It means the drug itself has turned up the volume on the very pathways it was meant to quiet. Third, the reward circuits have been recruited. So the dose is now also holding off a withdrawal that feels, to the body, exactly like the original injury getting worse. Remove the drug first and you unmask all three in the same week. That is not a taper. It is a cliff, and the outcome data on cliffs are not subtle. Among roughly 114,000 commercially insured and Medicare Advantage patients on stable long-term opioids, dose tapering was associated with higher rates of overdose and of mental health crisis in the year that followed. Among United States veterans, stopping an opioid prescription was associated with an increase in overdose or suicide deaths. The risk rose the longer the treatment had run before it was stopped. Neither study says do not taper. Both say do not abandon.

What replaces the opioid as the dose comes down?

The order here is fixed. Find the pain generator, treat the generator, and let the dose fall because the pain fell. A positive medial branch block followed by radiofrequency ablation can silence a facet joint for months at a time. A patient whose back stopped hurting in March does not need the same dose in April. A spinal cord stimulator or peripheral nerve stimulator is trialed before it is implanted. So the taper that follows it is planned around a result you have already felt. For the patient whose oral dose has become the disease, an intrathecal pump delivers medication at the spinal cord at a small fraction of the swallowed dose. That removes most of the whole-body load without removing the pain relief. For complex regional pain syndrome, ketamine by the sublingual or intranasal route works on a different receptor entirely.

The procedure buys the window. What fills it is the other half of the protocol, and it is not optional. Hyperinsulinemia (high blood insulin) and metabolic inflammation lower the threshold at which a nerve fires. So a patient whose fasting insulin is high hurts more from the same input and withdraws harder from the same dose. Fewer than 1% of this clinic’s chronic pain patients are metabolically healthy. That is why the taper plan and the bloodwork are written on the same day. Sleep is where the spinal cord damps its own alarm. A night-shift rotation at the refinery removes that window as surely as any drug. The hedonic treadmill matters too. Acellular carbohydrates and industrial seed oils were hammering the same dopamine circuits before the opioid ever got to them. So the food changes and the drug changes are one project. And isolation, the driver nobody bills for, is treated as a driver. Acceptance and Commitment Therapy is delivered in-house by a licensed, pain-trained behavioral clinician, because a nervous system being retrained to run on its own endorphins needs a reason to get out of the chair. Lifestyle and behavior are 40 to 50 percent of the plan, each piece with its physiological why. The taper is scheduled against the procedures, not against a calendar.

What do the CDC guideline and the trials actually say about tapering?

The 2022 CDC clinical practice guideline is not a mandate to taper anyone. It warns in plain language against abrupt discontinuation and against treating a dose threshold as a rule. It asks for individual decisions with the patient in the room. The systematic review prepared for the National Institutes of Health in 2015 found the evidence for long-term opioid benefit in chronic pain insufficient. It found the harms rise with dose. That is an argument for finding something that works better, not for abandonment. And the one large randomized trial pitted opioids against non-opioid medication head to head over twelve months. In Veterans Affairs patients with chronic back pain or hip and knee osteoarthritis, it found no advantage for opioids on function and slightly worse pain intensity. Read those three together and the position of this practice falls out of them. For irreversible pain the goal is not zero. It is the minimum effective exposure with function preserved and harm prevented. For reversible pain the goal is to reverse it so the question answers itself. What the trials could not capture is the patient they left out, which is most of the people reading this. That is the one with the high fasting insulin, the prior surgery, the shift schedule and the six-year prescription history. For that patient the evidence is thinner and the plan has to be more careful, not more rigid.

What monitoring comes with an opioid prescription here?

If a controlled medication stays part of your plan while the procedures do their work, monitoring comes with it. That means a written agreement, one prescriber and one pharmacy, periodic toxicology (drug) testing, and a check of the prescription records open to us in Illinois and Missouri. None of that is suspicion. Dosing a drug that suppresses breathing requires knowing what else is on board. A benzodiazepine or a gabapentinoid that nobody mentioned changes the math. The same visit that reviews the toxicology reviews the fasting insulin, because they are the same conversation about the same nervous system.

The cost nobody bills for

Discharging a dependent patient does not make the dependence go away. It moves it to an emergency department in Belleville, to a disability claim, to a family. Then it lands back at a clinic like this one with a worse history and a higher dose. The clinic that discharged them booked a clean quarter. The public paid for it. A physician who runs a practice with an MBA notices where the bill went, and refuses to write it.

Frequently asked questions

What happens at the first visit if I am already on an opioid?

The first visit is a diagnosis, not a transfer of a prescription in either direction. Nobody is cut off that day and nobody is refilled that day. Bring the bottles and the records, and what to expect describes the hour.

Does a taper mean withdrawal?

Done in the order described here, the pain falls before the dose does. The steps down are small and paced against how you are functioning. Withdrawal is the sign a taper is being run by a calendar instead of by a result. Radiofrequency ablation is the most common procedure that makes the first reduction possible.

How can an injection change a dose?

An injection aimed at the structure that is truly generating the pain removes the reason for the dose. An injection aimed by a scan alone removes nothing. That is why the diagnostic block comes first. When injections stop working covers what it means when a series of them has not moved the dose at all.

Why does a pain clinic check my blood sugar when we are talking about opioids?

Because insulin resistance lowers the firing threshold of the nerves the drug is quieting. It also worsens the sleep that a taper depends on. So a patient with a high fasting insulin handles a step down worse than one without. The mechanism is laid out in metabolic health and pain.

Is a pump a way to get a higher dose?

It is the opposite. An intrathecal pump places a small fraction of the oral dose right at the spinal cord. It is chosen for the patient whose whole-body dose has become the problem. And it is trialed before anything is implanted.

What does the CDC guideline say about tapering opioids?

The 2022 CDC clinical practice guideline is not a mandate to taper anyone. It warns in plain language against stopping an opioid abruptly and against treating a dose threshold as a rule. It asks for individual decisions made with the patient in the room. That is how the taper runs here. The dose comes down because the pain came down, not because a number on a chart said so.

What happens if you stop taking opioids suddenly?

Stopping first unmasks three problems in the same week. The structure that started the pain is still firing. The nervous system has adapted to the drug. And withdrawal feels like the original injury getting worse. Among United States veterans, stopping an opioid prescription was associated with more overdose or suicide deaths. The risk rose the longer treatment had run. That is a cliff, not a taper.

How do you get off pain pills safely?

Find what is generating the pain, treat it, and let the dose fall because the pain fell. That can mean a medial branch block followed by radiofrequency ablation. It can mean a nerve stimulator trialed before it is implanted, or an intrathecal pump. The procedure buys the window. Sleep, food changes, bloodwork for fasting insulin and in-house Acceptance and Commitment Therapy fill it. Each step down is small and paced against how you are functioning.

Related reading

• Metabolic health and pain
• Sleep, movement and behavior
• When injections stop working
• Intrathecal pump
• About Dr. Padda