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1/ I am so thankful the AMA featured our CDC submission on pain/opioids in their email blast to hundreds of medical societies and organizations nationally. I want to note key points made by AMA in their own superb letter (with @AjayManhapra @AJ_Gordon) https://twitter.com/AmerMedicalAssn/status/1273672443022974978
2/Opioid Rx's matter, still. But AMA states we now face an "unprecedented, multi-factorial more dangerous" crisis that can't be fully fixed through a "prescription opioid-myopic lens"- YES: provisional OD #'s show that in 2019 we REVERSED the progress of 2018. Lets rethink.
3/Doctors have made a number of changes
*Opioid Rx's fell by 1/3 from 2013 to 2018 (now well below 2006 Rx rates on per capita basis)
*PDMP use went up
*87k physicians obtained waivers to treat OUD
*Naloxone Rx's up 338% since 2016
*Opioid Rx's fell by 1/3 from 2013 to 2018 (now well below 2006 Rx rates on per capita basis)
*PDMP use went up
*87k physicians obtained waivers to treat OUD
*Naloxone Rx's up 338% since 2016
4/So what might help? AMA notes *continued barriers* on, let's see:
treating OUD,
treating mental illness,
multimodal pain care, protection of families w/addiction, access to OUD care in criminal justice
(ALL of this gets swept aside when we discuss "just opioid prescribing")
treating OUD,
treating mental illness,
multimodal pain care, protection of families w/addiction, access to OUD care in criminal justice
(ALL of this gets swept aside when we discuss "just opioid prescribing")
5/AMA *commends* @CDCgov and @HHSGov for issuing revised statements on individualizing pain care, including #opioid dose. Problem is that's hard when payers & pharmacies coated the CDC thresholds in iron.
6/In our letter to CDC we note that while @hhsgov urged caution in forcible reduction based on a dose figure, HHS' Office of the Inspector General doesn't agree. It terms all Rx>90 MME as the dose "to avoid" & refers to law enforcement accordingly https://oig.hhs.gov/oei/reports/oei-02-18-00224.pdf
7/AMA suggests fixes to all 10 recs from CDC but I resonated most with this: "public and private payer policies must be fundamentally altered and aligned to support payment for non-pharmacologic treatments and multimodal, multidisciplinary pain care" https://searchlf.ama-assn.org/undefined/documentDownload?uri=%2Funstructured%2Fbinary%2Fletter%2FLETTERS%2F2020-6-16-Letter-to-Dowell-re-Opioid-Rx-Guideline.pdf
8/Another AMA highlight is that while PDMPs can be useful, and have been aggressively promoted, the PDMP reports alone should not be used to suddenly stop opioids. Ditto for urine tests, as I wrote in @JAM_ASAM https://journals.lww.com/journaladdictionmedicine/Abstract/2017/12000/The_Unexpected_Urine_Test__A_Matter_Far_From.2.aspx
9/The theme here is IF health systems aim to "reduce opioid prescriptions", then that's what we call "de-implementation". It can be done well OR poorly. We need to refocus on "how". I spoke on this for @NIH HEAL initiative. Go to 38:34 to watch
10/Actual successful de-implementation, and not the crapfest* we're seeing requires engaging the perspectives of the people seeking health care, as @AcademyHealth notes: https://twitter.com/AcademyHealth/status/1273289825282646018?s=20
11/It shocks me to see that when patients speak on their own behalf there are organizations willing to issue the scurrilous charge, that they are paid by Pharma to speak. I cannot imagine the countless emails I received were funded by Pharma https://www.painnewsnetwork.org/stories/2020/6/17/you-ruined-my-life-patients-blame-cdc-guideline-for-poor-pain-care
12/A glaring gap in our discussion so far, one @cdcgov needs to also address, is the continued racial disparity and racism we display toward Blacks in pain care, an issue covered here: https://www.wbur.org/hereandnow/2020/01/15/black-americans-pain-opioids-racial-bias
13/In the end "nothing about us, without us". There's only so much the doctors can say. Even Ajay, Adam and I conclude with the same thing: talk to the people whose lives are being affected. https://medium.com/@StefanKertesz/our-response-to-the-cdcs-request-for-comment-on-management-of-acute-and-chronic-pain-5013778f9910
