Stefan Kertesz, MD, MSc Profile picture
Jul 29, 2020 7 tweets 3 min read Read on X
1/How to fix a problem in addiction treatment: a Train the Trainer model to expand #opioid use disorder treatment, tackling barriers: knowledge (providers & administrators), workload, innovation fatigue, telehealth, credentialing. In @SubstanceAbuseJ pubmed.ncbi.nlm.nih.gov/32697170/
2/The key was to address this reality: there is considerable failure to reach patients with OUD with medication based therapies in @VeteransHealth (same as outside) with only a small % (often just 1/4 or less) obtaining treatment
3/The SCOUTT Initiative drew 13 staff from each VA network, with 4 leaders in mental health, substance use, primary care, pain services, and 7 multidisciplinary staff (pharmacists, nurses, physicians, therapists) - for special training- conference & community of practice
4/They implemented two LEVEL 1 clinics (addiction treatment via primary care, mental or pain settings) within 12 months and another within 24 months. Heavy emphasis on nurse collaboration
5/As this began, SCOUTT leaders anticipated PRECISELY those challenges our health care system fails to consider when implementing change: competing time demands, stigma of OUD, overworked front line staff, and lack of incentive for real change. That required more resources
6/Crucial for reporters: Reporting on "lack of treatment" or "prescribing opioids" is too narrow. The question to ask, for rehabilitation, pain, or addiction is this:

"what tangible steps should health systems and their payers take to implement change successfully".
7/Hats off to this guy (left side) who led the SCOUTT Initiative to expand OUD treatment in VA, @vahsrd investigator, clinician and nurturer-in-chief @AJ_Gordon #mensch
#Tristan Image

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More from @StefanKertesz

Jun 5
🧵1/Our @uabmedicine Grand Rounds will feature a diagnostic showdown between Dr Martin Rodriguez and ChatGPT4

I am scared here because I don’t want AI to win Image
2/the case features behavioral changes, swearing, cognitive decline, cough, progressive weakness over 3 years.

I wonder about infectious and rheumatic disorders. Maybe primary neurological

Aspirations after a cognitive change is possible

Dr Rodriguez opens. Not much to go on. Image
3/ChatGPT generated a lot of text read by Dr Kraemer but it is pretty good, with emphasis on neurological disorders followed by a disclaimer “please note that this does not substitute for professional medical advice”. Both want more information
Read 15 tweets
Nov 15, 2023
Truth💣
1/ The “NARXCare” opioid Rx risk algorithm is in all Prescription Monitoring Databases,ie ~1 bn Rx’s/year

NOW in @JournalGIM
✅evidence does not yet exist to support it as safe or protective
✅It has flourished due to lack of federal oversight
link.springer.com/article/10.100…
Image
2/The authors, led by Dr Michele Buonara, review the core argument as one in which this algorithm with low evidence to its favor

and high risk of harm

has gone unregulated

despite apparently fulfilling @US_FDA criteria that mandate it be regulated Image
3/Nearly all prescribers and national pharmacies now see the Bamboo Health, Inc proprietary “NARXcare” algorithm in a more prominent position *than the prescription history itself” when they view a prescription history. Image
Read 10 tweets
Nov 3, 2023
1/Arguing for methadone deregulation, Dr. Ruth Potee notes that in an auditorium of 400 addiction specialists, almost NONE prescribe methadone (because they can't)

"Methadone is a miracle drug that no one has access to"

There are more people who offer Botox than offer methadone
2/With most blood pressure and anti-cholesterol meds, the number needed to treat to save one life is well over 100

With methadone, it’s 40

Number needed to treat to improve a life=1 #AMERSA2023
@AMERSA_tweets 3/Regulations for methadone care have not changed in 50 years.

How many other aspects of health care have not changed one bit in 50 years?

In the map: access to methadone care is almost completely absent in extremely large parts of the country.

-Dr Potee Image
Read 31 tweets
Sep 24, 2023
1/For patients on opioids, weighing “risks vs benefits” with shared decisionmaking – as CDC urged- may be out of reach for today’s doctors & patients.

Writing in @SAj_AMERSA @PoojaLagisetty & I propose weighing Harms of continuing vs Harms of reducing
A🧵
journals.sagepub.com/doi/10.1177/08…
Image
2/Opioid Tapering has proven a mixed bag. Research finds some patients ⬇️doses with no harm, but others suffer catastrophes

The CDC urged “shared decision-making” about risk & benefit

But for opioid BENEFITS, docs & patients routinely disagree cdc.gov/mmwr/volumes/7…
3/A patient may report an opioid benefit

Patient: “I can still do my activities”.
Doc: "No way, not really. I read the SPACE trial, and there is NO benefit (that would outweigh the opioids’ risk)”
"Shared decision-making" seems *doomed* here Image
Read 12 tweets
Sep 22, 2023
1/I watch with concern as DEA prosecutions of MDs still seem to rely on “they prescribed more than I would” despite a 9-0 ruling of
Supreme Court last year

Sudden termination of opioids & progressive abandonment of 5-8 million patients is dangerous

pressherald.com/2023/09/21/ken…
Image
2/In Maine the prosecuted Dr Norris is board -certified in addiction and runs an addiction treatment program.

Thus far, she has not faced discipline from her Board. The Maine based expert witness for the DEA *resigned from the case*

pressherald.com/2022/10/27/mai…
Image
3/the challenge is weighing Harm vs Harm

Nearly every addiction doc treating patients with addiction or overlap addiction+pain is walking a tight rope

The Rx risks a HARM

But a HARM may follow stopping the Rx: suicide or overdose

That is harm vs harm
seacoastonline.com/story/news/202…
Read 9 tweets
Jul 20, 2023
1/Even on inpatient rounds, it is possible to introduce the idea that addiction isn’t (only) in the brain.

I contrast @NIAAAnews “brain disease” against a behavioral economics vide substance use as a pattern of behavior occurring in relation to environmental context Image
2/On teaching rounds we read aloud and discussed the @NIAAAnews brain-science model of addiction, pulling just a few lines off their website Image
3/then we read lines from Chapter 39 of “Evaluating the Brain Disease Model of Addiction” - this presents harmful substance use as a pattern of behavior based on assessment of competing rewards, delay or uncertainty of desired rewards, risks and costs - ie behavioral economics Image
Read 7 tweets

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