Stefan Kertesz, MD, MSc Profile picture
Oct 13, 2021 7 tweets 5 min read Read on X
1/Prescription opioid counts have fallen to levels last seen in 1992,reports ⁦@US_FDA⁩ Corinne Woods, PharmD for workshop at Duke Margolis today
2/Prescription #opioid milligrams are at levels of early 2000s. That number is higher (relative to prescription count) according to @US_FDA Corinne Woods, PharmD at Duke-Margolis today - I think this difference reflects the patients with long term receipt.
3/Total milligrams and total count of oral tablets in an “initial prescription” have declined, reports @US_FDA Corinne Woods, PharmD to today’s session for Duke-Margolis and FDA (2 images here)
4/Opioid prescriptions to children have declined a good deal. Note this breaks our prescribers by specialty and that the x-axis is not the same in the two images (left vs right) reports @US_FDA Corinne Woods, PharmD at today’s session for Duke-Margolis
5/When buprenorphine is started for treatment of Opioid Use Disorder, it is now increasingly a treatment started in primary care. And nurse practitioners are playing a rising role. Report from @US_FDA Corinne Woods, PharmD
6/Summary points from @US_FDA - notes large ⬇️ in prescription, less of a decrease in MME, decline in overlap of benzodiazepine & opioids, and fewer patients starting (wait for final observations next!)
7/In the additional points, @US_FDA speaker notes that high level data is limited, that ⬆️Rx prescribing played a role in opioid crisis and acknowledges unintended consequences from reductions - thank you Corinne Woods, PharmD /fin

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More from @StefanKertesz

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
Jul 3, 2023
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.

or you can designate as zero
Read 17 tweets

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