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@NitaGhei @DanLairdMD 1/Just to be super clear: there is a strong relationship between prescribed #opioid dose & risk of overdose : the magnitude of that association & degree to which it is causal is not entirely clear. But I agree we should avoid escalating doses unless back is against a wall
@NitaGhei @DanLairdMD 2/However, if a person is stable at a given dose, even if we now say “gosh, wish it were not that high” there is no trial evidence that a reduction dose does improve safety. It is plausible (I offer the idea to my patients!) but no trial evidence .. & there is something key here:
@NitaGhei @DanLairdMD 3/The best advocates for taper are the ones who show great skill and sensitivity and patience in how they carry it out. Including a willingness to stop or reverse the taper (as Canadian Guideline supports) based on how patient does
@NitaGhei @DanLairdMD 4/Some advocates skilled at taper make the case for taper by all, assuming that (a) all docs will do tapers well if they just get new guidance & (b)health systems, payers & regulators will help them succeed. These unstated assumptions are at odds with reality @AJ_Gordon
@NitaGhei @DanLairdMD @AJ_Gordon 5/The reason CDC Guideline authors did speak up is because in real life, implementation of new policy & practice is often chaotic and not tied to careful assessment of the external pressures driving the change, the patients, or the resources necessary to change care successfully 
@NitaGhei @DanLairdMD @AJ_Gordon 6/There are two bodies of scholarship that explain why proposed plausible improvements to care can fail miserably and cause harm, and both have been ignored for the most past Policy Analysis and the Consolidated Framework for Implementation Research (graphic of latter)
@NitaGhei @DanLairdMD @AJ_Gordon 7/To summarize:(a) policies are _never_ fully rational(Policy Analysis insight @CairneyPaul &(b) Implementing practice changes in health care can be devastating when implementers ignore setting, context, resources, & stakeholders. That is how we proceeded with #opioids in pain.
@NitaGhei @DanLairdMD @AJ_Gordon @CairneyPaul 8/Finally- most OD events in the Rx receiving population are at low Rx’s dose. The higher dose confers some additional risk, but the event we are dealing with is heavily driven by other remediable factors - as repeatedly shown by Zedler, Bohnert, Glanz, Oliva - 4 papers there
