1/Until now, there has been no "easy way to ask" whether primary care providers feel ready to manage pain and opioid use disorder- That ends today, thanks to my collaborator Dr. @AllysonVarley, whose paper offers a 10-item survey: CAP-POD journals.sagepub.com/doi/full/10.11…
2/Combining qualitative & quantitative work, Dr. Varley & team (me included) derived a 10-item survey assessing primary care providers' self-rated
*desire to treat pain OR opioid use
*ability to assess risk
*trust in evidence
*patient's access to recommended therapies!
3/One use for a survey like this is to help health systems or payers *assess clinicians' readiness to adopt a systems-change to pain or OUD care*.
That matters because MOST changes in this space have failed, full-stop, to assess clinicians' capacity to participate in the change
4/One other concerning finding will resonate with patients and payers:Participating primary care providers had LOWER "Desire to treat" (either pain or OUD) & LOWER confidence in "Patient Access" to needed services, and higher "Trust in Evidence" & capacity in "Assessing Risk"
5/Hats off to a full team of coinvestigators at @UAB and @cappi_uab . And especially my colleague and collaborator @AllysonVarley
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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…
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
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.
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
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
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
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
2/On teaching rounds we read aloud and discussed the @NIAAAnews brain-science model of addiction, pulling just a few lines off their website
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
1/In thinking about the OPAL opioid Trial (as 1st line treatment for back pain) - and other trials, I want to model an idea that I welcome others to shoot down or support
Comparing mean effects of opioid to placebo as 1st line treatment
2/studying the average effect for a treatment with very ⬆️ variability of “benefit” and “aversive” responses is confusing
it makes comparisons to placebo a bit of a mess.
Here is my hypothetical graph of a placebo’s average range of aversive impacts and beneficial impacts
3/With placebo - I suggest- whatever bad effects people feel (even if they are not truly “caused” by placebo) or benefits are either along some narrow range.