🧵1/Our @uabmedicine Grand Rounds will feature a diagnostic showdown between Dr Martin Rodriguez and ChatGPT4

I am scared here because I don’t want AI to win 2/the case features behavioral changes, swearing, cognitive decline, cough, progressive weakness over 3 years.

I wonder about infectious and rheumatic disorders. Maybe primary neurological

Aspirations after a cognitive change is possible

Dr Rodriguez opens. Not much to go on.

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…
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

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

https://twitter.com/StefanKertesz/status/1720442676099617055

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

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…
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…

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…
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…

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 2/On teaching rounds we read aloud and discussed the @NIAAAnews brain-science model of addiction, pulling just a few lines off their website

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

1/A report in @TheLancetOncol describes loss of access to controlled drugs for many medical conditions because of strict & undisclosed med limits imposed by large pharmaceutical companies after opioid litigation thelancet.com/journals/lanon… 2/This is in part the result of $21 billion settlement between pharmaceutical distributors and 46 states' attorneys general in response to the opioid crisis

1/Many large database studies invite simple cause & effect assumptions actually contradicted by the data in the study itself.

This recent paper on household opioid availability and overdose is a case example. jamanetwork.com/journals/jaman… 2/This well-analyzed paper finds associations between personal receipt of opioid prescription and overdose and also between a household member’s receipt of opioid Rx and overdose, using appropriate household and medical records data. So far so good

1/This week two stunning reports from @nytimes & @VICENews document a trail of trauma to pain patients following law actions focused on opioid-prescribing physicians-

Strong reports from both @keegan_hamilton & @maiasz - 2/In ‘Entire Body Is Shaking’: Why Americans With Chronic Pain Are Dying"

@maiasz presents Anne Fuqua- who I met in 2017. She finds 932 suicides, 235 "documented with materials like news articles, suicide notes, family accounts & medical records"
nytimes.com/2023/01/03/opi…

1/The Economist recently declared that syringe exchange programs “kill” their clients, relying on a statistical modeling paper by @analisapackham

My biostatistical partner & I wrote the Economist - as our letter wasn’t published, we share it here 🧵

economist.com/united-states/… 2/Please note: we are responding to what we felt was inadequate reporting by @TheEconomist

We welcome scholarly work, including work by @analisapackham

There was some response to this scholar -personally- that was classless & cruel.

We respond to the Economist here…

1/There are 3 patient deaths in the 5 weeks since DEA revoked the certificate of one LA doctor who served “pain refugees”

I read DEA’s court filing- some patients had high doses & drug combinations. No allegation beyond that. @keegan_hamilton story on 2:

vice.com/en/article/wxn… 2/For the record, Mr Elliott (above) was not my patient

But I talked with him for 2 hours when his prior doc was shut down in 2018.

I wrote docs around the country asking for help. I wrote that suicide was the likely outcome if his care was not restored.

1/Many of us take 3rd grade arithmetic for granted.

We assume that if we reduce a numerator & not the denominator, the resulting fraction is smaller

A new study from Yale, as I read it, asks if this holds true with opioids in the numerator
🧵
mdpi.com/1660-4601/19/2… 2/The study computes the trend in % of motor vehicle accident (MVA) injuries where the adult had prior opioid Rx receipt

Numerator: opioid Rx received, prior to an injury
Denominator: MVA injuries

Focus: insured adults injured in MVAs, seen in ERs (n=142,204, 2014-2018).

1/22 years ago I wrote in the Boston Globe about my fear for the survival of my #homeless patient who was mostly demented, alcoholic, and often beaten up on the streets.

I have that in mind as we see reactions to New York’s plans to deploy an involuntary confinement response 2/That my patient would die was the concern brought to me by nurses who had heard from case workers who had seen him preyed upon.

What I discovered was that there was no path to protect him

1/Shortly after DEA revoked the certificate of the doc who cared for Danny & his wife, both died by suicide, this month

I had sought help for Danny in 2018, when he lost a prior doc, writing he would likely die by suicide if no help was found

The Vice team went to the funeral

https://twitter.com/VICENews/status/1597951100203798528

2/I told Vice that I can’t find anyone who believes all these patients should die,

Thus, I can’t understand why agencies act in a way that massively increases the likelihood of that outcome (even if you believe the doc was doing something wrong)

@JagsGatorsFish @GhanaboyPharmd @HealthyFla @CDCgov @WSJ 1/The revision, like its predecessor, urges appraisal of alternative treatments, benefit potential, risk potential & harm. It ⬇️ emphasis on simple binary rules that delivered a false impression of safety while, in reality, causing new harms highlighted by FDA, CDC & in research @JagsGatorsFish @GhanaboyPharmd @HealthyFla @CDCgov @WSJ 2/The loss of some of binary bold font rules from 2016- notably fixed limits on days prescribed & on doses - distressed some who believed that the rules had made patients safer. As a research scientist & addiction doc, i am saying the evidence did not align with the belief

1/As I said to @NPR the new @CDCgov Guideline on opioids is better, and I also disagree with key parts

But the #1 point:

protection for patients with long-term pain depends on 3 agencies NOW taking action:
@CMSGov @DEAHQ (DEA) and @NCQA

https://twitter.com/NPR/status/1588277608466501632?s=20&t=ANyXlPW-XRWHw9-QzCp_cA

2/The CDC's revised Guideline says - commendably- NOT to use doses caution points to set rigid performance incentives on DOSE or DURATION

If taken seriously
then National Committee for Quality Assurance *must reverse* the High Dose Opioid Metric punishing docs for dose >90 MME

1/Marijuana legalization in Uruguay 🇺🇾 was followed by a far smaller ⬆️ in use by teens & young adults, compared to Chile 🇨🇱 , where it was not.

The key may be in Uruguay’s approach, according to a new article in @AddictionJrnl onlinelibrary.wiley.com/doi/abs/10.111… 2/The difference between Uruguay’s legalization and Colorado’s is night and day, according to the editorial by Dr Julia Dilley- only cannabis plant/flower is legal. No vapes or edibles!

1/In response to this tweet, from a journalist alleging a “class divide with addicted homeless”, I will offer corrective facts

Among Americans entering treatment for opioid use disorder in the federal TEDS dataset, 12.5% were homeless.

https://twitter.com/lhfang/status/1582819953035517952

2/There are many reasons to be concerned that addiction treatment of high quality is not sufficiently available to ALL Americans, especially in states that fail to invest in it, but treatment for addiction is used by many who experience homelessness: pubmed.ncbi.nlm.nih.gov/1772151/

1/ a beautiful and serious reflection on a patient who doctors found “challenging” highlights the power of patients who insist on knowing and understanding and holding clinicians to account.

It also reminds me of key themes in our podcast On Becoming a Healer

https://twitter.com/adamcifu/status/1582751343810256896

2/“Sal” in this story has command of his illness and often tests his doctors, who then find him exhausting because he isn’t passive enough .. what many doctors are trained to do is objectify -

🧵The headline from a new @NEJM trial was
colonoscopy did not reduce risks of colon cancer death. I believe that the study limitations stood in the way of seeing reality here. Let’s talk it through (thread): nejm.org/action/doLogou… 2/Prior data led us to think more limited sigmoidoscopy prevents colon cancer death.
A 2014 RCT of 100k 50-64 year olds had 78k controls and 20.6k screened (63% adherent).
At 11 years f/u, colorectal cancer death was 27% lower among the screened. jamanetwork.com/journals/jama/…