Stefan Kertesz, MD, MSc Profile picture
Sep 30, 2020 8 tweets 3 min read Read on X
1/Canadian provinces that reduced #opioid prescribing the most also had the LARGEST increases in opioid overdose mortality in the 2-year period of 2016-2018 (r=0.63, p=.05, df=8) -it's striking to see significant correlations with n=10! bmcpublichealth.biomedcentral.com/articles/10.11…
2/The authors suggest that reductions in prescribed opioids create "supply gaps" that push the *non-medical opioid users* to riskier supplies.

However, I've become more concerned that some actual medical users (i.e. pain patients) also make that jump... like this:
3/In this Colorado case-control study, chronic opioid recipients who later developed new-onset heroin use were more likely to have had their prescription opioids stopped (38%) compared to those who didn't develop heroin use (22%) - sciencedirect.com/science/articl…
4/In that Colorado study 'prescription stoppages' were sometimes in response to concerning behaviors in patients- signifying that at least part of the time, the clinicians were responding to something that they didn't feel they could handle, or that scared them.
5/The Colorado study comes on the heels of ever more studies in which Rx opioid stoppage or taper is not followed by any improvement in patient safety, even though (in some of these studies) there are hints of "un-safety" in patients BEFORE the Rx stoppage.
6/The correlations that drove thought leaders to propose opioid taper as the focal point for safety efforts are now countered by *too many* studies finding no safety benefit to Rx opioid stoppage, under ordinary conditions of practice (example) bmj.com/content/368/bm…
7/I still assess, from the observational data, that escalating doses should be understood as risky, but not prohibited

And yes, there are situations where tapering doses is the next best step in care, provided clinician & patient are prepared to deal with messy consequences.
8/But the continued obsession with counting opioid Rx's, which now sit below 2006 levels, has not yielded the protective benefit one would have hoped for. Time to "measure the opioid crisis differently" as per this @TEDxBirmingham talk:

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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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