1/“Due to the increasing demands and changing nature in primary care, we will no longer manage chronic pain” as Mass. patient is told he will “taper off” in 1-2 months: I don’t know the clinic. I know the trend lines reflect impact of making a liability (the patient) unbearable
2/The overprescribed opioids’ role in contributing to problems of diversion & overuse drew a controlling reaction in which the Rx itself was seen as the prime target for reduction, by nearly all parties that could- simultaneously- affect prescribers’ sense of safety to practice 
3/Amidst #COVID19 - neither a urine drug test nor an in-person visit are strictly required by existing DEA rules, but DEA rules alone don’t determine the decision framework for prescribing clinicians deadiversion.usdoj.gov/GDP/(DEA-DC-02…
4/Clinicians have absorbed a collective message that situates them as “potential bad actors”. They are reacting, in part, to metrics such as “% of patients at risk of continuing on long term opioids” “% of patients receiving opioids at high dose” from @PQAAlliance @NCQA
5/Note: the warnings issued in 2017 about how these metrics would affect patient care were specific, shared with the very top decision makers, signed by people who worked on @CDCgov guideline, and the outcomes were just as bad as predicted medium.com/@StefanKertesz…
6/The outcomes papers do not tell a simple, causal story. But #opioid stoppage slow or fast, by clinics deciding that they can’t handle the pressure has not been shown to be safe.The papers of 2019-20 require another thread. All show clinical instability -journals.plos.org/plosone/articl…
7/But the story can be understood 3 ways. Analytically, as a “de-implementation” failure, where collision of a crisis, litigation, some good will,lack of understanding of pain care &a toxic environment helped drive clinicians away from vulnerable patients link.springer.com/content/pdf/10…
8/From a policy view, tacit acceptance that patients suffer harm as we “taper off”or”shut off” involves suspension of a customary norm in healthcare:leaders hold themselves accountable for harms,study them, and act decisively to stop them-That’s my @TEDx
9/Before the 3rd view, let me counter an occasional misinterpretation of my work. I never say all opioid reductions “caused harm” or there is “no benefit” to a more cautious #opioid Rx use. They are not magic 💊 but problematic . onlinelibrary.wiley.com/doi/full/10.11…
10/The 3rd way to understand how clinical practices can close off a large categories of patients, who receive #opioids, is that the policies put into play nationally, and the documents they cite, routinely discount the views of patients with pain, whose lives are affected.
11/On a more hopeful note: in 2019, 3 federal agencies (HHS, CDC, FDA) drew attention to harms observed from various improper invocations of CDC’s guideline. And a recalibration has been ongoing in some settings blogs.bmj.com/bmj/2020/03/03…
12/my Rec’s: (a) individualize care to combine evidence, clinical conditions, context & preferences (b)”opioid safety” work should be retooled as protecting _patients_ with complex illness rather than making _opioids_ safe (c)get patient/family views at every policy step /FIN
