1/ Yesterday, Patrick Allen, the director of the Oregon Health Authority @OHAOregon published an op-ed in the Wall Street Journal on.wsj.com/2wwOr9H, responding to an earlier op-ed from @slsatel and @StefanKertesz, regarding the OHA proposal for treating chronic pain.
2/ In the op-ed, Mr. Allen attributed a 17% decline between 2015 and 2016 in prescription opioid overdose deaths (best in the country) to a number of interventions, including prescribing guidelines and expanded coverage for non-pharmacological treatments for back and neck pain.
3/ It is certainly plausible that the actions of the OHA might have reduced prescription opioid overdose deaths, but there are a few sticking points that need to be addressed. First, there is no mention of the relative decrease in Medicaid vs. non-Medicaid populations.
4/ That's important because there is an implication that actions taken by Medicaid generalized to the entire population of Oregon, which could happen, but is unproven here. The alternative is that there was a MASSIVE decrease in Medicaid OD deaths, which is unlikely.
5/ Second, Mr. Allen includes the OHA back and neck pain program, but that program didn't go into effect until January 1, 2016, which is AFTER the time frame for the cited decrease in overdose deaths.
6/ It would be very difficult, if not impossible, to tease out the effects of all the interventions taking place in the 2015-2016 time frame, which are not limited to those listed by Mr. Allen. So, the effect of the neck/back pain program is undetermined.
7/ Consequently, using this decrease to support the efficacy of the neck/back pain program is fallacious on a number of grounds.
8/ No one that I know of has objected to the notion of increasing access to non-pharmacological pain treatments for people with other types of chronic pain. In fact, in my testimony, I specifically encouraged @OHAOregon to do that.
9/ Coupling that with a mandatory taper to zero opioids, however, is not required. It's not a case of "both or neither". It is possible to increase access to non-pharmacological treatments and take other effective steps to reduce opioid prescribing.
10/ I don't know of anyone who opposes using the lowest effective opioid dose possible. But getting there by mandating that people taper to zero is dangerous and unsupported by evidence.
11/ Mr. Allen states that a panel of health experts will consider the evidence to evaluate the proposal. I don't think they have the most relevant evidence, however. They don't have evidence about the effects of the neck/back pain program on affected Medicaid beneficiaries.
12/ The evidence needed would study the impact of this program on those beneficiaries. It would need to be a before-and-after look at affected individuals, or a case-control study comparing them to privately insured people with the same diagnosis. Or, in the best case, both.
13/ That research would need to look at a variety of outcomes: All healthcare utilization; rates of accidental overdoses, suicide, and all-cause mortality; rates of disability and actual hours worked; effects on mood and other measures of quality of life.
14/ There may be other outcomes, as well, (including opioid doses) but these would be a very nice start, and would tell us if the neck/back pain program is really a success, or if it's about to enter the 21st month of a 12-month program because it's actually not working.
15/ Many of us would be happy to work with OHA to design an effective comprehensive integrative chronic pain program, but we need to know the outcomes of the last experiment before we extend that experiment to others. I'm not sure an IRB would approve this experiment otherwise.
16/ For all the talk of insufficient evidence, this is an opportunity to actually gather some, and it appears to be going to waste. We need more evidence-based policy, but we first need to have the evidence to drive the policy.
17/ Let's face it: for EVERY pain treatment, pharm and non-pharm, we have low-to-moderate quality evidence of moderate effect sizes over the short term, and no long-term RCTs, only observational data. That's also true for research into opioid therapy risks.
18/18 So, let's all get real about what the evidence shows, and doesn't show, and let's set out to work together to gather more evidence to guide our policy-making. And stop the bold experiments on the most vulnerable citizens.
