1/A new @bmj_latest paper is seen by some as showing that 2 prior reports were incorrect in reporting major drops in opioid prescribing. Rather, this fine paper shows a problem in how US Rx reductions were achieved @mollyjeffery, @jsross119 @nilaydshah1
bmj.com/content/362/bm…
2/the headline I would offer is: “large, well-documented US opioid Rx reductions have not involved changing a long-term American habit of sloppy short-term prescriptions, but instead reflect changes in care for a small number of sick people on long-term prescriptions”
3//Here’s the report. Key endpoint is important (% of persons receiving an opioid Rx by quarter). No major decline found in 3 distinct insurance groups: bmj.com/content/362/bm…
4/to accept the conventional spin of “no drop in opioid prescriptions”, you have to reject 3 commercial reports as erroneous. Here’s one, from CDC’s excerpt of QuintilesIMS, 18.2% drop from peak in Rx by 2016, and 48% reduction in hi-dose Rx’s since peak of 2008, 10 years ago
5/Here’s another, from IQVIA showing 12% overall drop in 2017, and 16.1% drop in high-dose in 2017 alone:
iqvia.com/gated-form-pag…
6/ In reality, there is no contradiction, once you see that the BMJ paper’s headline result concerns persons who receive ANY opioid prescription, and most people who receive ANY opioid receive that Rx for short durations, at low dose.
7/In fact, many of these short-term opioid prescriptions are flagrantly stupid (or unnecessarily long), never consumed, harmful to the patient or ripe for diversion. Witness the report that ¼ of ankle sprains result in opioid Rx. washingtonpost.com/national/healt…
8/So how did total opioid Rx prescribed go down so MUCH in the US, if the % of persons receiving opioid Rx’s did not? By changing the care of long-term recipients. The BMJ paper itself tell us long-term recipients were a tiny percentage of the overall recipients:
9/Here, as in a prior publication in @AnnalsIM we find that 5% of opioid receiving patients account for 60% of morphine milligram equivalents
annals.org/aim/article-ab…
10/And indeed the @bmj_latest authors do confirm that it’s in those high MME users that reductions were prominent, although they state it a little opaquely, “use was somewhat less concentrated in the top percentiles of opioid users over time”
11/Of course we already knew that, because when you add together the CDC/Quintiles and more recent IQVIA reports, one finds that total high-dose (>90 MME) prescribing dropped >50% since 2008.
12/It’s much easier for insurers to disapprove, & regulators to target, high doses than for anyone to regulate ankles in ER's. I’m NOT saying that dose escalations were wise or always helpful in the first place. Just that high dose, long term patients are the easy targets now.
13/But note: “easy targets” for regulatory action are also the people many studies show us are sick with multiple conditions, where comprehensive care would be the more humane approach to care, whether they are on opioids now, or not ncbi.nlm.nih.gov/pmc/articles/P…
14/To repeat, the biggest achievable drop in MME, at the system level, involves big changes to the care of small number vulnerable patients, a step sometimes tolerated and sometimes traumatic, as we wrote last week: nature.com/articles/s4139…
15/ In our recent paper in @addictionjrnl, we call this the “arithmetic problem” where the perceived need to make a number drop quickly to please policymakers is in tension with our moral obligations as caregivers onlinelibrary.wiley.com/doi/abs/10.111…
16/In sum, new report doesn't contradict the prior ones. It shows us HOW we are making prescriptions drop. Personally, I think we could make better choices. huffingtonpost.com/entry/governme…

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More from @StefanKertesz

Feb 20
1/For Veterans who are feeling 'in crisis' or believe they are at risk of suicide, I want folks to be aware of the National Veterans Crisis Line:
Phone: 800-273-8255, option 1
Text message: 838255
Facetime Chat also available
veteranscrisisline.net
2/I encourage folks to at least check out the website. They can and do refer to local VA Medical Centers for suicide prevention support & clinical services. One does not need to be "VA-eligible" to use this service
3/When a person hears from from another with suicidal feelings, it can be hard to know what to say or do. I encourage "helpers" to be respectful, non-judgmental, to say (in your own words) "I am hoping this isn't a situation where you dying is the way this goes"
Read 4 tweets
Feb 10
1/The revised draft version of @CDCgov opioid Rx guideline is covered appropriately here by @DrewQJoseph

This guideline must be assessed not just for what it says,but for how it may or may not guide institutional actions that abused the prior guideline & could do the same here
2/This means that whatever arguments we may offer about the *science*, a key challenge is what to do about other agencies, including those in @HHSGov itself, that decided to make a *misreading* of the 2016 Guideline key to their regulation of care, despite resultant patient harm
3/The most crucial examples are the Office for the Inspector General of HHS and the nonprofit @NCQA, because the @OIGatHHS refers prescribers for criminal investigation, while the @NCQA obligates the hand of all payers and providers
Read 14 tweets
Feb 8
1/“Maus” author Art Spiegelman participated in a *wonderful.* discussion of his book sponsored by 4 faith groups in Tennessee

The webinar is at bottom of the report.

Min 30-45 highlight some key points not discussed in most coverage

newschannel9.com/news/local/mau…
2/the Board was upset by sexuality - the book depicts Art being urged by his father not to mention a premarital affair.

Art’s choice: to make the contract with his *readers* rather than his father

He knows it depicts him being “a jerk” but this is wise -
3/We tell so many stories that are designed to clothe the story-teller in virtue or omniscience.

But adolescents have excellent BS-detectors.

They pay more attention to honesty
Read 7 tweets
Feb 3
1/There is a new “Lancet Commission” report on the North American opioid crisis.

It is led by @KeithNHumphreys and includes @DrSeanMackey & @ChelseaLShover

I will share a few shots of some messages & recs as it is behind paywall

Selectivity is unavoidable. It is 50 pages!
2/These are the key messages of the Commission
3/The Commission does see the opioid overdose/poisoning crisis as a result of a multi system regulatory failure
Read 11 tweets
Feb 3
1/This is an update 🧵re: our research on suicides after Rx opioid reduction
Clinical context of SuicIde following OPIOID transitionS
(CSI OPIOIDs)
TL;DR: we're progressing. The pilot study is NOW.
A "bigger" study is coming
We are preparing docs for the funder & ethical review
2/Background: CSI OPIOIDs does *not* seek more statistical papers.
There are already *3* papers that find a tendency of higher suicide event frequency in persons who are tapered versus those who are not:
pubmed.ncbi.nlm.nih.gov/33863865/
jamanetwork.com/journals/jama/…
bmj.com/content/368/bm…
3/I'm going to detour one tweet here on ADVOCACY:
In my role as ADVOCATE, not researcher, I have been decrying the imposition of nonconsensual changes to care of disabled patients, changes lacking evidentiary support, since 2017 (here with @AJ_Gordon ) statnews.com/2017/02/24/opi…
Read 14 tweets
Feb 2
One of the most fascinating pieces of evidence in the Washington opioid litigation (against distributors) is this chart

1: I credit anyone's ability to diagram a problem

2: It's crazy to diagram problems of opioid prescription without referring to clinicians or patients
2/It is *harmful* to make clinicians invisible from the chain of accountability in our drug death crisis.

Civil litigators like to portray the medical profession understood as "putty". For people who like cop-outs and shirking responsibility, this is just fine.
3/But there's no drug company that convinced med schools to NOT prioritize training in addiction, in pain, in rehabilitation or in long-term care of complex problems.

And that choice, by OUR profession, is a big part of why many docs were pliant to marketing pushes
Read 5 tweets

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