1/The message from @AmerMedicalAssn to “Stop Scope Creep” flags a signal in opposition to the lessons I gained from 24 years of care for persons experiencing homelessness.
2/I can imagine some specific tensions that do arise for generalist MDs like me if payers supplant us fully in favor of other clinicians - but a broadcast hashtag #StopScopeCreep runs smack into many other competing and serious problems
3/First: in my world of caring for persons experiencing homelessness, I have been teamed up with Nurse Practitioners and Physician Assistants and RNs whose training and life experience are absolutely crucial, and compensate for my limitations
4/For patients with high levels of adversity and trauma in life, often it is the physicians who have re-enacted aspects of trauma in health care: sometimes it requires a non-physician to engage, often with a nursing disciplinary background. That is our team by the way :
5/Pharmacists don’t “replace physicians” but there is a significant amount of guidance they do provide and medications that they do help manage in large health systems.
6/#scopecreep sometimes is necessary. After interviewing homeless care teams, I heard this: docs who work with patients who are homeless sometimes must take on nursing & social work labor, or the right and necessary things don’t move forward for the person in front of us!
7/I admire and appreciate @AmerMedicalAssn for much crucial work on multiple issues right now, including pain & opioids. However I think the matter of “Scope” needs some re-deliberation. Ask: What is the goal here and what do patients need and whose help do we need?

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More from @StefanKertesz

24 Mar
1/Large studies show that in long-term recipients, opioid taper may offer benefit but is *often* harmful (an unclear balance).

The patient experience deserved attention. This new paper delivers:

"I felt like I had a scarlet letter" @DrugAlcoholDep sciencedirect.com/science/articl…
2/Interviews with 41 persons tapered (⬇️>50% ) were open. The framework for assessing stigma allowed that it may include “societal-level conditions, cultural norms, & institutional policies that constrain the opportunities, resources, and wellbeing of the stigmatized”
3/Major finding: "Participants identified themselves as overlooked and negatively impacted by measures implemented during the pharmacovigilance period, including various tapering initiatives"
Yep, I've witnessed that.
Read 10 tweets
17 Feb
1/I'm excited that Dr. @AjayManhapra is presenting on concerns about mandatory opioid taper for VA's MAT-VA journal club, based on our shared paper... he notes Human costs of mandatory and widespread opioid taper
2/He cites @BethDarnall as the best available study, noting that even when one offers the best support system, a significant % of patients do not have a reduction in pain or pain worsens.
3/In a way that will seem controversial, he proposes that opioid therapy is not exactly an analgesic. This is daily use of an addictive substance that offers relief, where only a minority develop addiction.
Read 20 tweets
8 Jan
1/Nice viewpoint out today: "Balancing the Risks and Benefits of Benzodiazepines" -authors note risks of these drugs and their utility, in light of @US_FDA changing the label to highlight risks jamanetwork.com/journals/jama/…
2/FDA's revised warning will more thoroughly cover risks, and the authors endorse that "increased caution regarding benzodiazepine use is warranted; fewer benzodiazepine prescriptions are needed" ... with a careful stipulation...
3/Benzodiazepine risks needed to be highlighted, "However, when considered without an appropriate patient-centered context, this enhanced warning statement might lead to fewer appropriate prescriptions and unintended consequences" - this should echo what happened with opioids
Read 9 tweets
3 Jan
1/FYI:Opioid Rx’s ⬇️ 60% vs 9 years ago.

Outcomes have not been good. OD deaths are way ⬆️, & patients traumatized

This thread covers 4 years of my peer-reviewed articles.

Let’s recalibrate policy, measure what we are doing, and LISTEN to the folks whose lives are at stake
2/This is the overall policy review of how we got here and how we mis-allocated the response (with @AJ_Gordon) ,

and why policy winds up (inevitably) being less than rational in the real world @AddictionJrnl onlinelibrary.wiley.com/doi/abs/10.111…
3/This piece says why efforts to “Turn the Tide” with a narrow focus on Rx risked a Riptide for patients, as fentanyl deaths rose.

The article led me to brief then Surgeon General @vivek_murthy in 2017- who shared this concern completely tandfonline.com/doi/full/10.10…
Read 12 tweets
31 Dec 20
“Why did so many physicians become Nazis?” – this new essay bears on us, the non-Nazi doctors. In short, “science” can be invoked by immoral agents, & science language can seduce us into societal plans that override our duties to individuals @tabletmag /1 tabletmag.com/sections/histo…
Germany was extreme, of course.

Over 50% of doctors joined the Nazi party. There, Jews, gays & disabled persons were designated a disease on the German “body”. Ridding Germany of them was seen as good science.

We need not project the US will follow that, ever /2
But the US & other nations have not been alien to an immoral use of science-based authority.

Germany’s Laws for the Prevention of Genetically Diseased Offspring were based on American laws, passed earlier. We should all know about Tuskegee
/3 cdc.gov/tuskegee/timel…
Read 15 tweets
15 Dec 20
1/This week in @journaljgim: “Promoting Patient-Centeredness in #opioid Deprescribing: a Blueprint for De-implementation Science”

Tools of “deimplementation science” should guide evaluation of health care changes - w/@BethDarnall @AllysonVarley
2/Opioid prescribing has ⬇️37% since its peak in 2011. Today, many agencies agree that “deprescribing” was not carried out in ways that consistently protected patients.

We ask “how can well-intended changes to care transpire in ways that are unsafe or harmful?” 2019 CDC Surveillance Report, IQVIA data
3/De-implementation= “reducing or stopping practices that are ineffective, unproven, harmful, overused, or inappropriate”
With opioids, that could be not starting, stopping or reducing.For us, this does *not* reflect a commitment to opioid elimination from care.h/t @VPrasadMDMPH
Read 15 tweets

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