I caught a snippet of this on @NPR this morning, and was immediately disappointed. This sort of framing is irresponsible. Here’s the hook: the pandemic is causing a rise in overdose deaths (obv true) partially because people have unemployment money (!!!).
From an overdose story: "He was lonely. He was depressed. He didn't have a reason any more to get up and keep going. And then, all this money flows in because of unemployment. So you're isolated, you have lots of money, and your coping skill has always been drug use."
The focus on the money here is wild. The idea seems to be that stimulus differentiates the current recession from others in which OD mortality didn’t increase. But you know what else is different? EVERYTHING. Because fucking COVID. It’s a recession defined by isolation.
And if you ever actually talk to people who use drugs, you’ll quickly learn that when they want to use drugs, they typically find a way to pay for it. That’s the hustle. What money actually does is allow people who use drugs to eat and pay rent—things that may drug use *safer*.
So there’s a formal problem with this argument, since the conclusion simply isn’t justified. But there’s also a serious *moral* problem with this frame, since it seems to suggest a policy solution: don’t give increased unemployment, since people will use it on drugs.
That’s some seriously stigmatizing shit. And it’s precisely the kind of thing that politicians will pick up—whether because they believe it, or because it serves their ends—and wield as a weapon against poor people.
Giving struggling people (during a pandemic!) money doesn’t cause overdose. We know plenty of what leads people to use drugs and plenty about what factors lead drugs to be more deadly. This analysis overlooks both and is dangerously misleading.
• • •
Missing some Tweet in this thread? You can try to
force a refresh
Very happy for this paper to be out in the world. In it, I argue that non consensual discontinuation of opioid therapy for stable legacy patients is wrong. This is true even if it means prescribing opioids for a patient indefinitely.
1. Holding that reducing overprescribing entails forced deprescribing overlooks the difference between initiating and continuing opioid therapy. 2. Physical dependence changes the risk-benefit profile of opioids, as the harms of withdrawal and increased pain must be considered.
3. Lastly, the fact that the medical establishment put legacy patients into their current predicament should count in favor of patients being given a voice in their care. Having made patients vulnerable, they deserve a say in how that vulnerability is resolved.
Two days before the end of 2019, my dad collapsed suddenly, purple by the time he hit the floor. His partner, mere seconds away, is an experienced nurse, and she—and eventually EMS—did CPR for more than 20 mins. They shocked his heart back into rhythm, and that’s when it started.
He is a pretty standard ICU patient: 70 year old male, comatose after sudden cardiac arrest, almost certainly some degree of anoxic brain injury, but the real question is how much. I wasn’t at all sure he’d still be alive by the time I got to him 1600 miles away. But he was.
So the waiting and slow, complex diagnostic and prognostic progress began. My sister is a nurse. I’m a bioethicist. And my experience so far is of never-ending days of utter confusion, while different teams of clinicians tell us pieces of sometimes-relevant information.
I had a really interesting conversation with a pain doc. He had read some of my work and wanted to chat. Despite his basically confirming what I know, I can’t shake how DARK his knowledge of pain care is.
Thread.
I’ve argued that we have to be careful of chilling effects on prescribing—not only for new patients but for patients already dependent on opioids. In his state, the chill is complete. Even as a pain doc, there is significant risk for taking on any patient on high dose opioids.
If he does take them on, he has to immediately taper them, so he can tell the inevitable medical board investigation that he’s ‘doing the right thing’. But most of his colleagues simply won’t accept high dose patients.