@Jinxthejjinx@ChadDKollas@OregonAdvocate@PainMedJournal@LabGirl_Chloe@supportprop 1/I see this paper as direct, and not one that is terribly supportive of tapering policies (and it's good to report this): it's clear from this report that taper often fails, and that switch to buprenorphine helps some, and at least as often fails with others.
@Jinxthejjinx@ChadDKollas@OregonAdvocate@PainMedJournal@LabGirl_Chloe@supportprop 3/Here it says that among the subset of 89 who got all the way below 90 MME, the majority (52%) had ⬆️ of pain, but 24% had no change and 24% had ⬇️ of pain. This means that taper may help some pain, but more often it does the opposite. That's the data.
@Jinxthejjinx@ChadDKollas@OregonAdvocate@PainMedJournal@LabGirl_Chloe@supportprop 4/There was a group that switched to buprenorphine. Please note, I personally have patients where that switch was helpful, and others who needed to go back. This paper finds that among 43 who switched, 18 had ⬆️pain, 4 had no change, and 21 had ⬇️pain.
@Jinxthejjinx@ChadDKollas@OregonAdvocate@PainMedJournal@LabGirl_Chloe@supportprop 5/Here's my take: the authors "believe" in the program they offer. They assert (in the discussion, which is where authors do speculate) that what they did resulted in safety and prevented redistribution of medication in the community.
They have no evidence for those speculations
@Jinxthejjinx@ChadDKollas@OregonAdvocate@PainMedJournal@LabGirl_Chloe@supportprop 6/This study and others show us that policies to broadly incentivize opioid dose ⬇️on high-dose patients are not justifiable, but certainly an attempt at taper is something patients may seek to choose. Such findings are:
a)some feel better
b)others feel worse
No panacea
@Jinxthejjinx@ChadDKollas@OregonAdvocate@PainMedJournal@LabGirl_Chloe@supportprop 8/I want to separate research from advocacy here. From the start, as soon as I saw some patients harmed , I began advocating. Injuries to patients are ethically unacceptable. But even there I stick to what I see, and what evidence can show. Stick to truth, always.
@Jinxthejjinx@ChadDKollas@OregonAdvocate@PainMedJournal@LabGirl_Chloe@supportprop 9/The blowback I faced, just sticking to the facts and the science as I know it, was fierce & a bit scary. One day we can explore that, but not now. The next crucial step is to learn more, so we can speak with more clarity about what is happening to patients and families, now
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1/This is a sobering, important article, with devastating observations from a formerly homeless Veteran. Mailing medication to someone who is homeless? Yikes.
2/Our research finds that persons who are homeless, Veteran or not, are often subject to misunderstanding or stigma, and that aspirations for what makes care good are not interchangeable with mainstream concepts - @AllysonVarleyjournals.sagepub.com/doi/abs/10.117…
3/In large VA-funded research studies. we find that intentional efforts to tailor the design & delivery of primary care for persons experiencing homelessness, prevents unfavorable experiences in care! journals.lww.com/lww-medicalcar…
1/Listening to @1a "Against the Pain" - @1a is to be commented for covering this issue Hats off.
I wish to share a thought on a form of bias built into NARXCare as it is obvious, correctable, and harms patients. wamu.org/story/21/11/11…
2/Dr. Nishi Rawat of Bamboo Health (provider of the NARXCare algorithm to assess overdose risk) describes the NARXCare product they put onto the screens of doctors (via Prescription Drug Monitoring Programs) as an "objective summary". About that...
3/Dr. Rawat's definition of NARXCare covers 2 distinct function. One is a graphic summary of the Rx's received by a patient (if the data are accurate, this is helpful).
But the concerning one is an "Overdose Risk Score"
1/It is bad that clinician performance on matters related to the opioid crisis is *still* being measured in terms of # of opioid prescriptions.
These metrics, which ape prior metrics that drove the original⬆️ reject the approach we normally require for measuring quality of care
2. To be clear. Optimal health care metrics require
a) clear denominator of eligible patients with the condition
b) clear evidence that the treatment's provision is wholly good or its nonprovision wholly bad
c)evidence that imposing the metric leads to improvements in health
3. For example, a metric such as "provision of cervical cancer screening" would be BAD if it includes persons with no cervix either because of hysterectomy, or because they are cis-male.
1/This report on the homeless “sweep” at Boston’s Mass & Cass highlights a tragedy to which the city contributes, and some helpful points for people thinking about unsheltered homelessness wgbh.org/news/local-new…
2/The City’s accumulation of persons who are unsheltered partly results from the City’s closure of its Long Island Shelter, which was often used by people with drug use disorder - I used to work there
3/But it is also true many people really do not tolerate congregate shelters at all. Close quarters with people who might be intoxicated or paranoid is actually not an easy thing.
1/For any discussion of homelessness - please remember: the key driver of *total number of people homeless* in any area of the US is the number of units that are affordable to poor renters
2/Efforts to blame homeless numbers in West Coast cities to "fentanyl" are not based in evidence. Here's an opioid overdose per capita map. States with horrific overdose crises often have lower homeless counts per capita than ones like California, where the OD rate is lower
3/Still not convinced? San Francisco's homelessness is high per capita. It's fair market rent for a 2-bedroom apartment is $3500!!! That translates downhill to poorer folks not being able to afford an extra bedroom or accommodate family members with problems of any kind