Will Pill Control “Fix” Our Problem?

Here is a video of Dr. Kertesz’ criticism of how the CDC guidelines have been turned into regulations in various health care settings:

Will Pill Control “Fix” Our Problem?: The Allure of Simple Solutions

Sound medical decision-making and
how propaganda is hurting otherwise stable patients

Three points:

  1. The CDC guideline was a serious response to a serious problem
  2. Emerging practices don’t respect it and people are being hurt
  3. How did we get here?

CDC recommendation 7

  • For patients on opioids already, evaluate benefits and harms.
  • If benefits do not exceed harms then work with patient to reduce dose
  • No proposed dose target

Key questions:

  1. Was this patient better off?
  2. Should patient consent matter?
  3. Do we normally carry out involuntary procedures on otherwise stable patients on the premise that we will protect them, absent prospective data?

Powerful rhetoric by leaders played a role

  • “almost all the opioids on the market are just as addictive as heroin” and “for the majority of patients, the risks of opioids will outweigh the benefits for chronic pain. For the vast majority of patients.”
    –Tom Frieden
  • We are seeing “the suspension of evidence-based decision-making”
  • The statistics and data are available but we are deciding not to use the data

The allure of simple solutions

  • Don’t neglect the need for evidence
  • Involuntary tapers and discontinuations… Are based on observational correlations of dose with risk
  • Assumes reducing dose will reduce risk
  • Not from trials

The treachery of observational data

  • Let’s re-understand risk
  • Dose risk correlations are not equal to dose response curve
  • Dose is correlated with mental and social vulnerabilities and these multiply risk by 2 to 20%
  • We need care, not pill control: mental health, pain education, and often monitored continuation of opioids

Opioid guideline work group made recommendations to CDC:

  1. Support integrated care for people with chronic pain
  2. Monitoring of guideline implementation for evidence of impact and unintended consequences and modification when warranted

Recommendations:

CDC:

  • Firmly clarify seventh recommendation
  • Report the harms of ignoring it
  • Assemble stakeholders for outcomes assessment plan
  • Investigate outbreak of suicides and Public suicidal ideation

Regulators and payers:

  • Embrace care and risk mitigation
  • Stop number chasing based on observational correlations

Chasing a number is how we got here

 

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