1/There is one upcoming Supreme Court Case to follow for anyone who cares about criminal prosecutions of doctors for prescriptions of opioid medicine - specifically Rx where intentions were to deliver appropriate medical care: Ruan v. USA supremecourt.gov/docket/docketf…
2/The central question comes down to whether it is a federal crime for a physician to prescribe opioids, in a way where the government’s experts contend it was imprudent or unwise, when that physician intended and reasonably believed they were acting within standard of care
3/Most prosecutions of non-MDs under the Controlled Substance Act require “mens rea” criminal intent.

If I sell you a PlayStation, believing it is a PlayStation, which turns out to have cocaine inside, I can’t be convicted of a criminal violation of CSA. No criminal intent
4/when it comes to prosecuting doctors, the federal circuits have split in regard to what instructions are given to juries. Some have effectively gutted the matter of intention and resolved it down to “standard of care”. What that means is as follows#
5/A higher than ordinary prescriber- perhaps unwise but well intended, or perhaps the only one left who won’t abandon legacy patients- is evaluated by the government’s paid experts for anything they can call a “red flag”.
6/The experts are often highly paid docs who lack training in addiction or pain but who avow black & white approaches. ie Never combine Opiods and Benzos. Always order GC/MS urine tests. A doc who didn’t hold to those rules is adjudicated as, in effect, not acting like a doctor
7/In the Ruan case the jury instruction made good faith intentions of the docs immaterial. But that meant doctors can be convicted even if they were attempting to protect the patient. Mens rea doesnt apply. Different federal circuits disagree
8/under this legal standard of prosecution, which is favored by DEA, a doctor who abruptly cuts off all prescriptions, even if that causes deaths and contravenes guidance from HHS, is not liable to any risk of criminal prosecution, and only rarely at civil risk
9/I note that among the prosecutions & investigations that come to my attention, often Boards working in tandem with DEA, cases come down to often just a few Rx’s, where the expert paid by the DEA feels like they would have taken a different decision. Pill mills are long gone.
10/For people who care about this, watch the filings (link below)

No one can predict the outcome. But it will influence the safety of patients who are currently on chronic opioids and being cut off abruptly, as several studies now show /fin

supremecourt.gov/docket/docketf…

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More from @StefanKertesz

20 Dec
1/There is a *reason* that the decline in Veterans experiencing homelessness is that steep.

It reflects the adoption Housing First approaches, as well as could be done, by @DeptVetAffairs

Anyone who wants to see our research on strengths & weaknesses of this work, see 🧵 Image
2/Bear in mind that our work considered Housing First with “eyes open” as I had raised relevant questions as to what it can deliver, most especially where addiction is part of the picture pubmed.ncbi.nlm.nih.gov/19523126/
3/However, on whole and despite the very real challenges that will happen when housing people with serious mental illness and addiction challenge, the data have been reassuring as to potential for success, like this pubmed.ncbi.nlm.nih.gov/21285095/
Read 7 tweets
10 Dec
1/It is helpful to see a review of the concerns raised by professionals & patients prior to the publication of the 2016 CDC Opioid Prescribing Guideline - take a look. I will add highlights from my 2016 docket submission. Nearly all issues re-emerged in published research
2/My own 2016 submission to CDC’s docket was- as is appropriate- respectful of authorial expertise and good intentions.

But my top line concerns were 4.

1/Inappropriately broad conclusions derived from untestable propositions

stefankertesz.medium.com/considering-cd…
2/ CDC’s Dose-related recommendations prioritized *relative* risk over *absolute* risk, and minimized consideration of interaction of risk and protective factors -

This is different from approaches applied to nearly all other risk evaluations in medicine (eg NSTEMI, A-fib)
Read 8 tweets
22 Nov
1/Suicides that follow prescription opioid reduction are a tragedy we need to discuss openly, and mainstream reporters almost never do.

This article by @DrewQJoseph is commendable.

Our work to learn from families who have suffered these losses is linked in the next tweet
2/Our team at @UABNews has been running a preliminary version of a larger planned study, a survey to reach family survivors to learn about these tragedies one by one, like safety investigators would an airplane crash. We think that is the place to start. It is called CSI:OPIOIDs Image
3/As a clinician, I have been advocating to address these losses since 2016.

In 2018, I began urging federal study of the individual suicides, because large database statistics, concerning as they are, don’t reveal the circumstances around losses. We have to look closely.
Read 8 tweets
14 Nov
@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 2/Here, in the paper we see that when high dose patients are referred, 36% leave before or after taper initiation. Wait for the pain results, next This is a chart showing 801 patients with opioid receipt wer
@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.
Read 9 tweets
13 Nov
1/This is a sobering, important article, with devastating observations from a formerly homeless Veteran. Mailing medication to someone who is homeless? Yikes.

Let’s learn from the unfavorable experiences.

(Research on that in next tweet)
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 - @AllysonVarley journals.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…
Read 5 tweets
11 Nov
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"
Read 16 tweets

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