Prescription Opioid Reductions and Suicide: What Should Caring Physicians Do in the Face of Uncertainty?

The narrative that getting patients with chronic pain off opioids makes them safer was reinforced by a recent paper that got substantial media attention showing an association with reduced suicide rates at the population level -- But other data, at the patient level, shows an increased rate of suicide. 

Which is closer to the truth? And, if there's an answer, how does it apply to the individual patient? Is it ever okay to taper a patient when it’s not a shared decision? 

How do you talk about it, and does the power dynamic between doctor and patient affect such conversations? Are patients with opioid dependence too impaired “to know what’s good for them”?   

How does one navigate what can feel like a minefield: legal risks, angry patients, moral injury and, above all, wanting to do the right thing? Do the answers to these questions have broader implications for the physician-patient relationship and good doctoring? 

(This episode refers several times to "engagement" and "boundary clarity." Check out episode #15 for an exploration of these concepts.)