High-dose patients suffer greatest opioid cuts

Here are a series of tweets from Stefan Kertesz (@StefanKertesz Aug 2, 2018), explaining a recent BMJ study that shows no decline in the numbers of people receiving opioids.

1/A new @bmj_latest paper is seen by some as showing that 2 prior reports were incorrect in reporting major drops in opioid prescribing. Rather, this fine paper shows a problem in how US Rx reductions were achieved
https://www.bmj.com/content/362/bmj.k2833

2/the headline I would offer is: “large, well-documented US opioid Rx reductions have not involved changing a long-term American habit of sloppy short-term prescriptions, but instead reflect changes in care for a small number of sick people on long-term prescriptions”  

3//Here’s the report. Key endpoint is important (% of persons receiving an opioid Rx by quarter). No major decline found in 3 distinct insurance groups:
https://www.bmj.com/content/362/bmj.k2833
https://twitter.com/StefanKertesz/status/1025210111797743616/photo/1

4/to accept the conventional spin of “no drop in opioid prescriptions”, you have to reject 3 commercial reports as erroneous. Here’s one, from CDC’s excerpt of QuintilesIMS, 18.2% drop from peak in Rx by 2016, and 48% reduction in hi-dose Rx’s since peak of 2008, 10 years ago
https://twitter.com/StefanKertesz/status/1025210114045894661/photo/1

5/Here’s another, from IQVIA showing 12% overall drop in 2017, and 16.1% drop in high-dose in 2017 alone:
https://www.iqvia.com/gated-form-page?redirectUrl=%2f-%2fmedia%2fiqvia%2fpdfs%2finstitute-reports%2fmedicine-use-and-spending-in-the-us-a-review-of-2017-and-outlook-to-2022.pdf%3f_%3d1525217580070

6/ In reality, there is no contradiction, once you see that the BMJ paper’s headline result concerns persons who receive ANY opioid prescription, and most people who receive ANY opioid receive that Rx for short durations, at low dose.

7/In fact, many of these short-term opioid prescriptions are flagrantly stupid (or unnecessarily long), never consumed, harmful to the patient or ripe for diversion. Witness the report that ¼ of ankle sprains result in opioid Rx.
https://www.washingtonpost.com/national/health-science/a-quarter-of-adults-with-sprained-ankles-were-prescribed-opioids-in-the-er/2018/07/27/112cf916-9119-11e8-8322-b5482bf5e0f5_story.html?utm_term=.bf09d23459b3

8/So how did total opioid Rx prescribed go down so MUCH in the US, if the % of persons receiving opioid Rx’s did not? By changing the care of long-term recipients. The BMJ paper itself tell us long-term recipients were a tiny percentage of the overall recipients:

9/Here, as in a prior publication in @AnnalsIM we find that 5% of opioid receiving patients account for 60% of morphine milligram equivalents
http://annals.org/aim/article-abstract/2653713/distribution-prescription-opioid-use-among-privately-insured-adults-without-cancer
https://twitter.com/StefanKertesz/status/1025210126251302912/photo/1

10/And indeed the @bmj_latest authors do confirm that it’s in those high MME users that reductions were prominent, although they state it a little opaquely, “use was somewhat less concentrated in the top percentiles of opioid users over time”
https://twitter.com/StefanKertesz/status/1025210129518612482/photo/1

11/Of course we already knew that, because when you add together the CDC/Quintiles and more recent IQVIA reports, one finds that total high-dose (>90 MME) prescribing dropped >50% since 2008.

12/It’s much easier for insurers to disapprove, & regulators to target, high doses than for anyone to regulate ankles in ER’s. I’m NOT saying that dose escalations were wise or always helpful in the first place. Just that high dose, long term patients are the easy targets now.

13/But note: “easy targets” for regulatory action are also the people many studies show us are sick with multiple conditions, where comprehensive care would be the more humane approach to care, whether they are on opioids now, or not
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3641146/

14/To repeat, the biggest achievable drop in MME, at the system level, involves big changes to the care of small number vulnerable patients, a step sometimes tolerated and sometimes traumatic, as we wrote last week:
https://www.nature.com/articles/s41394-018-0092-5.epdf?author_access_token=kWh1gbuVjg-vE_P1uTBO-9RgN0jAjWel9jnR3ZoTv0N595hNdqXCaMyZLdQjiLhsmmPDXD9_hEomUaJHPkT8FDuy2LTIdrfDOJyzWcOZouwN1rR08tIU_b4eODE0DllbRSjegM468m5VHfiXjywxxQ%3D%3D

15/ In our recent paper in @AddictionJrnl, we call this the “arithmetic problem” where the perceived need to make a number drop quickly to please policymakers is in tension with our moral obligations as caregivers
https://onlinelibrary.wiley.com/doi/abs/10.1111/add.14394
https://twitter.com/StefanKertesz/status/1025210140851691520/photo/1

16/In sum, new report doesn’t contradict the prior ones. It shows us HOW we are making prescriptions drop. Personally, I think we could make better choices.
https://www.huffingtonpost.com/entry/government-crackdown-opioid-prescriptions-pain-patients_us_5b51ec57e4b0fd5c73c4a42e

3 thoughts on “High-dose patients suffer greatest opioid cuts

  1. Scott michaels

    Absolutely! I an living proof. While on high dose for my many spinal conditions, i was able to function, hug my kids, go for wals, cleab the house. Now im bedridden 20/24 hrs a day. Even though i still get some medication, it relieves about 30% of the pain. I have become a spectator in my own life when i was an active participant. Every other treatment cost me my life savings because opioids were MY LAST CHOICE. Now that i found out they are the ONLY thing that gave ne my life back, they have hern taken away. Not for anything i have done but because fools use heroin and overdose. I STILL DONT SEE THE JUSTIFICATION. WE ARE NOT JUNKIES NOT DRUG SEEKERS NOR DO WE GO ONLINE FOR ILLEGAL DRUGS TO GET HIGH. NOT ONLY HAD MY PAIN WORSENED BUT BECAUSE OF THAT MY BODYBAND MIND ARE BOW SHUTTING DOWN I AM CONSTANTLY DEPRESSED, ALWAYS ALONE AND HAVE ABSOLUTELY NO SUPPORT FROM THE MEDICAL COMMUNITY. I WOULD BE BETTER OFF IF U WERE SHOOTING UP HEROIN TUEN TAKING MY PAIN RELIEVERS AS DIRECTED. IT SEEMS LIKE DIRTY JUNKIES THAT WILL KILL YOU FOR A HIGH ARE MORE IMPORTANT THEN VOTING CITIZENS THAT WORK OR WORKED FOR 40 YRS OR VETS YHAT LIST LIMBS FIGHTING FOR A COUNTRY THAT REALLY DOESNT GIVE A SHIT ABOUT THEM AND THIER PAIN.
    THIS IS A SAD TRUTH IVE WITNESSED A JUNKIE GET NEEDLES AT A WALGREENS WHILE AN 80 YR OLD MAN WAS GETTING YELLED AT BY A PHARMACIST OVER HIS VIVODIN PRESCRIPTION. GOD FORBID HE MIGHT BECOME AN ADDICT. AM I THE ONLY ONE THAT SEES THE MORONIC MENTALLITY HERE.

    Liked by 1 person

    Reply
    1. Zyp Czyk Post author

      I think the problem is that the anti-opioid zealots have convinced everyone that all long-term use of opioids is actually addiction, and that we’re taking our opioids regularly to prevent painful withdrawals, not “real” pain.

      If you argue, they just say you’re “in denial”, which further “proves” you have an addiction. It’s awfully hard to disprove such circular logic if a person wants to believe it.

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      Reply
  2. Pingback: A doctor crusades for caution in cutting back | EDS and Chronic Pain News & Info

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