@andrewkolodny called our article (with Diane Hoffman & @ChadDKollas in @statnews on the harm to patients who legitimately use opioids for pain in the current regulatory environment, which begins with the AMA’s recent action stating the same, dishonest. statnews.com/2018/12/06/ove…
1/While the subject of opioids inspires polarizing and often simplistic or even eviscerating attacks, we need to welcome questioning and different perspectives in open debate, so here are his points and our response:
2/Claim A: He takes greatest exception with our citation of the risk of developing and addiction from prescribing opioids long term at .06-7%.
3/ A/1.The CDC cites Edlund (.06-7%) as a summary of the data around the risk for incidence of new of opioid use disorder in long-term patients- i.e., the risk for addiction.
4/A/2. What @andrewkolodny refers to is cross-sectional preference - which is a distinct epidemiological concept, something he (as a researcher and not a lawyer) undoubtedly knows.
5/A/3 The .06-7% range is similar to @NIDAnews Director Nora Volkow’s assessment of risk at less than 8%. nejm.org/doi/full/10.10… (Opioid Abuse in Chronic Pain Management — Misconceptions and Mitigation)
6/A/4. Fellow @supportprop member, Dr. David Jurrlink, has been quoted in the press as saying that the 8% number may be high. Said Juurlink of this estimate, "I think it's on the high side.” tonic.vice.com/en_us/article/…
7/B. Claim B: He takes issue with our citation to the Department of Justice/DEA when they said that the rate of opioid prescribing is at an 18-year low.
8/B.1 We cited DOJ because it was the most recent solid source. We could’ve cited to FDA’s 15-year low (which reflects quantities of opioids dispersed from retail pharmacies). fda.gov/AboutFDA/Repor…
9. B/2/4.There are different ways of measuring the drop in prescribing. Rate of prescribing and total MMEs will yield different results.Regardless of how it's measured, opioid prescribing has dropped substantially since 2011 (and high dose prescribing has dropped since 2010).
10. Claim C: Our citation of the SERMO study misleads.
11/ C 1 .We first cite to the recent survey by Dr. Terri Lewis that shows an alarming number of pain patients experiencing medical abandonment and disruption in care. This is from a patient pov.
12/ C2/2. We then wanted something from physicians. This study shows that physicians are prescribing fewer opioids. It also shows that some are doing so against their best clinical judgment. We did not say all of them were
13 C/3 3.When examining an emerging pattern of harm which has not yet been studied - - this seems a fair citation for the principle.
14/ Claim D: Claim 4: That providers can gain exemptions for patients from the slew of acute care restrictions in state legislatures.
15 D 1 1.We take pains in the piece to discuss the difference between formal policies and the places those policies are falling down in practice.
16 D 2 2. We focused patient impact (beginning with AMA President Dr. McAneny’s patient who attempted suicide after a pharmacist denied his medication. The point: there are now many sources of oversight - pharmacies, insurers, state Medicaid providers, other regulatory bodies...
17 D. 3. ...i.e., Many points of vulnerability at which the system may break down in practice even for someone formally exempted from mandates. On this one point we could’ve drafted more artfully but the import is plain from the piece.
18. Claim E - the most puzzling of all -drug overdoses from prescription opioids are down. We agree.
19. E 1. That was PRECISELY OUR POINT. Prescribing is down - during the same years in which the crisis became recognized as an epidemic & yet overdoses have skyrocketed driven by illegal fentanyl, its analogs and heroin.
20 E 2.Overdose deaths are increasingly related to a tainted street drug supply (which may also play into the rise those related to stimulants (cocaine and meth)
21 A few points: First, Importantly, Dr. Kolodny fails entirely to acknowledge the main point of the article - the danger to patients who legitimately use prescription opioids.
22/ Rigid pendulum swings claim victims on both sides and, however laudable the goal of a systemic reduction in opioids, the CDC guideline is being applied in one-size-fits all ways that are evincing signs of harm to patients.
23/ His three Pinocchio rating was glib, but intellectually dishonest. And his recent doubling down in the mainstream press on a description of prescription opioids as ‘heroin pills’ - is stigmatizing to those who need these essential medications.
24/ Addiction & persistent pain are specters of our time – they are dual but should not be dueling epidemics. Relative to their prevalence both are radically are under-addressed in medical education, treatment & research and are subject to considerable misperception and stigma.
Also It is possible to protect against harm to patients from overprescribing and harms to patients who require treatment with prescription opioids. Take the case of British Columbia.
After adopting the 2017 Canadian Guidelines on prescribing, British Columbia saw discrimination against pain patients. Its College swiftly responded not by withdrawing its guideline but by adding a provision to protect pain patients from abandonment & discrimination.
