Policy of chasing numbers did not and will not work

A Crisis of Opioids and the Limits of Prescription Control – by Stefan G. Kertesz and Adam J. Gordon – 23 July 2018

Here is just the abstract of this interesting article:

A rise in addiction and overdose deaths involving opioids in the United States has spurred a series of initiatives focused on reducing opioid risks, including several related to prescription of opioids in care of pain. Policy analytic scholarship provides a conceptual framework to assist in understanding this response.

Prior to 2011, a “policy monopoly” of regulators and pharmaceutical manufacturers allowed and encouraged high levels of opioid prescribing.

The authors then point out that the debate has been cornered by an “advocacy coalition” of anti-opioid fanatics.  

This permissive policy fell apart in the face of adverse outcomes brought to public attention by an “advocacy coalition” consisting of

officials, [like the CDC bureaucrats who issued such blatantly biased guidelines]

thought leaders, [or at least those who believe they are thought leaders even without a lot of thinking – like A. Kolodny]

journalists [who have uncritically copied whatever drips out of the “thought leaders” mouths]

interest groups  [like the recovery industry and stockholders of the buprenorphine business]

who shared common beliefs. [thanks to the relentless PROPaganda spread by anti-opioid activists]

This coalition has generated a more cautious prescribing regime that has incentivized involuntary termination of opioids in otherwise stable patients, with resultant reports of harm.

Its emphasis on dose reduction regardless of outcomes in some ways mirrors the prior focus on minimizing pain scores, regardless of outcomes.

Central to the present analysis is that policies cannot be comprehensively rational; rather, they emerge from a range of actors and agencies constrained in their ability to

  • assimilate complex data,
  • objectively evaluate the data, and
  • to command necessary resources

in an iterative, rapid response fashion.

The imbalance between strong prescription control and weak pain and addiction treatment expansion exemplifies the policy scholar’s notion of “bounded rationality.”

Results have been suboptimum: opioid prescriptions have fallen, but harms to pain patients and overdose deaths have risen.

U.S. policymakers could revise course through a more thoroughgoing engagement with patients, families and communities now coping with both pain and addiction.

You can download a PDF of the article for free without any kind of payment at https://rdcu.be/3uns  (that is the temporary ‘free download’ site and may expire after a day or two.

Here is the regular site for the article, where it’s still behind paywall until we fix it:


And here’s the press release from the University of Alabama where Dr. Kertesz works:

New efforts to control opioids become ‘funhouse mirror image’ of prior policies – July 24, 2018 – by Adam Pope

In a critical analysis of U.S. opioid policy, published today in Addiction, University of Alabama at Birmingham Professor Stefan Kertesz, M.D., and University of Utah Professor Adam Gordon, M.D., describes the swing in U.S. policies from encouragement of opioid prescribing to today’s increasingly rigid restrictions as simplistic responses to a complex human challenge.

“Neither the policies of yesterday nor those of today can be entirely rational,” Kertesz explained.

Our task was to explain how our collective irrationality has changed over time when it comes to opioids.”

The paper lays out some of the factors that lead policymakers to look for easy answers to complex problems, including pain and addiction.

The result, they write, is that insurers, legislators and other regulators are influenced by

“highly-informed advocates who can sway policy by predigesting data in ways that often reflect their own interests.”

This describes exactly what A. Kolodny and PROP have been doing. They got out in front of this crisis and managed to preset the public’s perception that the “opioid crisis” is about prescription drugs.

In the paper, Kertesz and Gordon… say the typical narrative that unscrupulous drug companies duped physicians and innocent patients is simplistic.

And wrong!

It neglects most efforts to understand how and why people use drugs or the communities from which they come. It presents doctors and patients as victims, rather than as people who also made decisions they may regret today.

Further, they argue, a simplistic narrative has led to simplistic policy responses, where controlling prescriptions has come to look like the easy answer.

They cite two major reports from 2017 that called for opioid prescribing restrictions. Both touched on addiction treatment, but neither demanded new funds to pay for treatment.

The result is a situation in which opioid prescriptions are “subject to an array of conflicting, high-stakes imperatives from an alphabet soup of regulators, employers and payers” who see reducing prescriptions as an easy numeric target, and very often the only target worth pursuing.

2016 Guideline on prescribing opioids from the Centers for Disease Control and Prevention… has been turned into a weapon against patients with pain, many of whom are now seen as liabilities by pharmacies, insurers and doctors.

we have also personally witnessed and otherwise appreciated an increasingly brutal effort to reduce prescriptions and reduce doses, without patient consent or in a non-patient-centric way. That’s wrong, too,” Gordon said.

The authors described a policy shift from

minimizing pain scores as the “5th Vital Sign”
minimizing “milligrams prescribed” (i.e., opioids).

“The new prescription control framework is a funhouse mirror image of the prior monopoly,” Kertesz wrote in the new piece.

“What was virtuous under the prior regime was to chase a number — the pain score — using opioid prescriptions, even as naysayers pointed out that people were being harmed.”

“What is virtuous under the new regime is to chase new numbers — opioids prescribed — even as naysayers point out other people harmed.”

The authors… favor restraint in starting opioids and greater efforts not to traumatize the patients who currently receive them.

Authors: Kertesz and Gordon are internal medicine physicians who have focused their research and clinical work on the primary care of patients with addiction and other vulnerabilities.

1 thought on “Policy of chasing numbers did not and will not work

  1. canarensis

    couldn’t sleep last nite so I spent a long time noodling around on the web. Ran across a dire (from our perspective) paper published in the BMJ. “Science Daily” published on it (scanning some of their other stories tells me they’re firmly in the PROPanada pocket). But this one sez the # of scrips for pain meds have NOT declined, as opposed to what everyone else is saying. It’s an absolute miracle of data manipulation, flagrant flimflamming, and statistical gymnastics (for one thing, the figures against which they’re comparing scrip numbers are from…..1999, i.e. just before they decided that pain was real & should be treated).

    So they’ve got these 20 year old numbers. Even if the rate of scrips for pain meds didn’t change, there’d still be more scrips because there’s a whole bunch more people now than 20 years ago, & they’re older.

    Oh yeah –it also says (with an implied gasp of horror at the thought of these people being junkies) that the largest percentage of the prescriptions went to –wait for it– disabled people. How’s that for a cataclysmically moronic “DUH!”? It’s like declaring with great shock that the majority of people who use wheelchairs are disabled. I very nearly head-slapped myself into a coma when I read it.

    I think it’s going to be very hard to rebut this asinine thing (like it has been for the fubared Krebs study) partly because most news outlets don’t allow comments, partly because most people won’t read farther than the headline, & partly because most people don’t understand statistics at all anyway (I’m not an expert at ’em by any means, but had to internalize some while working in medical research & other science my whole life). And the really eye-rollingly idiotic bits are way down at the bottom, by which time 99% of the people who DID read beyond the headline would’ve gone on to read “Garfield.”

    So, I dunno if you want to try to deal with it –you’d do a far better job than I could– but thought I’d mention it to you. I apologize if I’m being presumptuous in sending you stories/links; if you want me to quit sending crap your way, please tell me (tho I won’t stop reading & commenting on the pieces you do post, I’m not going to flounce off in a snit :-) .

    I don’t want to overwhelm you, but that’s the downside of you doing such a great job of parsing out these things…as a wise person said, the reward for doing a good job is usually another, harder job.

    btw, i’d check your BP before reading it…it’s a doozy.


    Liked by 1 person


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