Thread by @JillPiggott

What have false assumptions about rx #opioids cost people in #pain? Damn near everything.

@Brian_Goldstone's report ought to be required reading for every #PCP & every legislator who wants to play doctor. #MedicalTwitter harpers.org/archive/2018/0…

For 4 yrs, an rx #opioid let Austin Sell escape the cage of pain, care for his kids, study to become a physician asst to help others w/ #ChronicPain. Then lawmakers in DC imposed a limit on what his clinic could prescribe. "And that was it. The app'ment lasted about 10 minutes."

Dr @StefanKertesz told @Harpers: “In a time of incredible tragedy, there’s a desire for something simple to latch onto as a way of explaining it. A story that has a clear-cut villain, with doctors as dupes and patients as innocent victims, is about as easy to sell as any story.”

[JP: If medical #opioid use were the cause of the #overdose crisis, reductions in scripts would result in reductions in deaths. In fact, again this year as in years past, we hit a record low in scripts & we hit a record high in ODs.]

Goldstone: #Opioid med is "often framed as a zero-sum dilemma: relieve pain or prevent addiction?" But the question is "premised on a misconception: namely, that #addiction is rampant, even inevitable, among patients who are prescribed opioids for pain on a long-term basis."

[JP: Politicians & policymakers often confuse physical dependence & addiction. A wide range of drugs cause physical dependence & require tapers (not fast stops), including caffeine, steroids, antiepileptics, antidepressants, & blood pressure meds.]

FDA Commissioner Scott Gottlieb told Congress: "Someone who is physically dependent on opioids as a result of the treatment of pain but who is not craving more or harming themselves or others is not addicted.”

[JP: #Addiction thru medical use is "very rare," as the @AmericanCancer Society puts it. Studies cited in the CDC's 2016 Guideline found an average 97% unremarkable use. The 3% included non-addictive physical dependence & "long use."]

Goldstone: A "hunger for quick solutions — & a neglect of the latest research on both #addiction & #overdose — has provoked a pendulum swing." Post-CDC 2016, more than half of US states enforce #opioid restrictions by law.

#Medicare, #Medicaid, private insures, & pharmacies like #CVS all limit doctors' ability to prescribe an entire class of FDA-approved medicines for many of their sickest patients. Hospital administrators pressure doctors to stop prescribing #opioids.

"A growing number of physicians, for their part, have decided that the legal & financial liabilities are too great & felt compelled to forcibly taper their high-dose patients—or simply stop seeing them altogether."

The DEA--"taking it upon itself to determine what counts as a 'medically necessary' drug regimen--has accepted the surrender of more than 3,000 prescribing licenses & revoked another ninety-nine. Medical providers have been put on notice: if in doubt, don’t."

"Men & women who had been stable for years on #opioid medication, with no history of substance abuse or violations of their #pain contracts," have seen "their prescriptions suddenly tapered or stopped completely."

[JP: 2019 FDA warning: rapid/sudden #opioid discontinuation causes "uncontrolled pain, psychological distress, & suicide": "Patients may attempt to treat their pain or withdrawal symptoms with illicit opioids, such as heroin, and other substances.”] fda.gov/drugs/drug-saf…

[JP: Multiple studies show that deaths by OD & suicide go UP, not down when rx #opioids are reduced or stopped. #Vets whose med was stopped were 6 x more likely to harm themselves than those who continued treatment (Demindenko Gen Hosp Psych 2017).] suicideinfo.ca/wp-content/upl…

[JP: “Attempts to discontinue #opioid therapy to reduce the risk of #OD & adhere to prescribing guidelines may lead patients to be exposed to variability in opioid dosing," which triples their risk of OD (Glanz JAMA 2019).] jamanetwork.com/journals/jaman…

[JP: Discontinuation of #opioid therapy in primary care was associated w/ a nearly 3-fold increase in overdose deaths compared to those who remained on medicine (James, Jnl Gen Int Med 2019).]
link.springer.com/article/10.100…

[JP: Physicians aren't required to track or report whether their patients die after being taken off an rx #opioid. Researchers traced #vets whose rx was stopped in FY 2013 & found 2887 were dead from OD or suicide. That's 90 fewer than died on 9/11.] bmj.com/content/368/bm…

Goldman reports on an MD fired because he prescribed #opioids: "to his mind, these were essential drugs, & taking them away from patients who needed them was tantamount to depriving diabetics of insulin."

A form letter went to out to people being forced off medicine: "'Please be aware that arguing or complaining about changes in your prescriptions will not alter your clinician’s care plan.' Those who did complain...were told that they were welcome to seek treatment elsewhere."

What Goldman found in #Montana is happening in #Maine & across the country: There is no "treatment elsewhere." In the "name of public safety," the well-being of millions of people in #pain has been deemed "expendable."

While patients committed suicide & became disabled, Benefis clinic in MT denied abandoning them or setting dose caps & claimed their center was "built on a multidisciplinary, holistic model that tailors evidence-based treatment plans to an individual’s medical needs."

Austin Sell was forced to drop out of college when Benefis stopped his #opioid rx. He "could no longer sleep or go to work, & found even the most mundane tasks, such as getting his kids dressed & fed & dropping them off at school, nearly impossible to carry out."

For all this, Goldman writes, "#pain research remains startlingly underfunded & undervalued. In American medical schools, the average number of teaching hours on pain is 9; in the average veterinarian curriculum, it’s 45."

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