1/The revised draft version of @CDCgov opioid Rx guideline is covered appropriately here by @DrewQJoseph

This guideline must be assessed not just for what it says,but for how it may or may not guide institutional actions that abused the prior guideline & could do the same here
2/This means that whatever arguments we may offer about the *science*, a key challenge is what to do about other agencies, including those in @HHSGov itself, that decided to make a *misreading* of the 2016 Guideline key to their regulation of care, despite resultant patient harm
3/The most crucial examples are the Office for the Inspector General of HHS and the nonprofit @NCQA, because the @OIGatHHS refers prescribers for criminal investigation, while the @NCQA obligates the hand of all payers and providers
4/The OIG has, since 2016, mis-cited the 2016 Guideline as detailing a dose >90 mg as “to avoid”.

OIG never acknowledged that even in 2016, CDC declared a dose >90 could be justified.

It also never acknowledged that the CDC didn’t call for forcible taper of all patients! Image
5/Similarly @NCQA has long held all health care organizations to a standard dose quality metric of first 120, later 90, without allowance for either the prior CDC-acknowledged need to ⬆️ dose sometimes, or for the reports of harm following dose reduction- ncqa.org/hedis/measures…
6/To explain: the words of CDC in 2016 never justified the @NCQA quality metric that in turn spurred forced dose ⬇️ across the board

I personally, by phone, warned their Vice President in 2017 that early research data showed harm & death would result. No impact. I wasn’t alone
7/A list of respected experts affirmed that concern, in 2017, to @NCQA including @DrChinazo (who directed this cycle of the Opioid Guideline Workgroup) and powerful respected voices who had advised CDC.

None of these people led NCQA to alter course stefankertesz.medium.com/an-opioid-qual…
8/Even after CDC, FDA & HHS all cautioned against mandating forced opioid dose reduction in 2019, NCQA’s “High dosage” HEDIS measure continues, even now, to incentivize the dose reductions that these 3 federal agencies all said merited caution
s21151.pcdn.co/wp-content/upl… Image
9/Scientific side note: there exists some real (& causal) association between Rx dose and risk for a patient. Benefits of dose escalation are unproven.

However the Rx dose alone was never the only risk factor, and usually not the main one (excerpt) stefankertesz.medium.com/our-response-t…
10/so we are left trying to guess something:

The key question for the safety of patients comes down to whether a revised Guideline will be enough to induce agencies like NCQA, DEA & to alter their frameworks to stop harm, even when they disregarded authoritative concerns
11/A confession: I have been on the front lines of responding to traumatic stoppages and seen they were not scientifically justified, and they involved wholesale abrogation of core ethical responsibilities to patient safety.

That was, my @TEDx talk: Image
12/But to be honest, I have absorbed the trauma. Like any person who is traumatized, I actually can’t be sure I trust that the trauma will stop.

I would call for assurances that might not seem necessary to a person to a person who has not been confronted with the harms directly
13/Ideally, any revised Guideline must include a program to de-implement the misapplications of the prior one.

Ideally, as part of revision, @CDCgov will explain what new actions it will take to correct the misuse and mistreatment of patients

I’d love to help!
14/As for myself, I intend to continue to study the scientific statements in the revised Guideline, and to listen to people who are experiencing the impacts of the last one.

You can review and comment here regulations.gov/document/CDC-2…

/fin

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More from @StefanKertesz

Feb 8
1/“Maus” author Art Spiegelman participated in a *wonderful.* discussion of his book sponsored by 4 faith groups in Tennessee

The webinar is at bottom of the report.

Min 30-45 highlight some key points not discussed in most coverage

newschannel9.com/news/local/mau…
2/the Board was upset by sexuality - the book depicts Art being urged by his father not to mention a premarital affair.

Art’s choice: to make the contract with his *readers* rather than his father

He knows it depicts him being “a jerk” but this is wise -
3/We tell so many stories that are designed to clothe the story-teller in virtue or omniscience.

But adolescents have excellent BS-detectors.

They pay more attention to honesty
Read 7 tweets
Feb 3
1/There is a new “Lancet Commission” report on the North American opioid crisis.

It is led by @KeithNHumphreys and includes @DrSeanMackey & @ChelseaLShover

I will share a few shots of some messages & recs as it is behind paywall

Selectivity is unavoidable. It is 50 pages!
2/These are the key messages of the Commission
3/The Commission does see the opioid overdose/poisoning crisis as a result of a multi system regulatory failure
Read 11 tweets
Feb 3
1/This is an update 🧵re: our research on suicides after Rx opioid reduction
Clinical context of SuicIde following OPIOID transitionS
(CSI OPIOIDs)
TL;DR: we're progressing. The pilot study is NOW.
A "bigger" study is coming
We are preparing docs for the funder & ethical review
2/Background: CSI OPIOIDs does *not* seek more statistical papers.
There are already *3* papers that find a tendency of higher suicide event frequency in persons who are tapered versus those who are not:
pubmed.ncbi.nlm.nih.gov/33863865/
jamanetwork.com/journals/jama/…
bmj.com/content/368/bm…
3/I'm going to detour one tweet here on ADVOCACY:
In my role as ADVOCATE, not researcher, I have been decrying the imposition of nonconsensual changes to care of disabled patients, changes lacking evidentiary support, since 2017 (here with @AJ_Gordon ) statnews.com/2017/02/24/opi…
Read 14 tweets
Feb 2
One of the most fascinating pieces of evidence in the Washington opioid litigation (against distributors) is this chart

1: I credit anyone's ability to diagram a problem

2: It's crazy to diagram problems of opioid prescription without referring to clinicians or patients
2/It is *harmful* to make clinicians invisible from the chain of accountability in our drug death crisis.

Civil litigators like to portray the medical profession understood as "putty". For people who like cop-outs and shirking responsibility, this is just fine.
3/But there's no drug company that convinced med schools to NOT prioritize training in addiction, in pain, in rehabilitation or in long-term care of complex problems.

And that choice, by OUR profession, is a big part of why many docs were pliant to marketing pushes
Read 5 tweets
Feb 2
1/The White Coat ceremony ideally would disclose what the profession knows about itself, wrote @SaulWeiner

“We have to be candid about our own imperfections. You probably won’t always be treated respectfully. We apologize in advance for that”

“On Becoming a Healer” (2020)
2/“We don’t know which among you have an open heart and an open mind, and which have just learned to appear that way.

We’ve done our best to screen out the latter, but medical school admissions is an imperfect process”
3/“During the early years of training you may be in survival mode..so that you can get through all the stuff we foist on you to memorize. You won’t need much of it when you practice medicine, but a fair amount of the content will be on board exams”
#TwitterGIFs
Read 5 tweets
Jan 27
The next CDC Opioid Guideline draft is coming:

Be ready to speak LOUDLY to protect patients who were *not protected* by institutions that gave that the 2016 Guideline regulatory force, without regard to the the complexities of scientific evidence
2/My 2016 comment to CDC anticipated such harm:

“As medical boards, insurers and government agencies enforce this guideline, prescribing differently from the topline recommendations is likely to become onerous, leaving many patients in the lurch”

stefankertesz.medium.com/considering-cd…
3/Many of us didn’t fully anticipate that patients would be abandoned,

Or that DEA would use that threshold to investigate doctors,(and to seek criminal convictions)

But I now have observed that is the reality
Read 12 tweets

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