Clear thinking about opioid metrics: Twitter Thread by @StefanKertesz:
With the callous form letter below, a patient’s doctor’s office announced they simply wouldn’t be treating chronic pain anymore and would only offer 2 more months of tapering before essentially “kicking them out”.
While I understand that doctors are under tremendous pressure around prescribing pain medication, I’m shocked that such a dismissive move isn’t malpractice.
1/“Due to the increasing demands and changing nature in primary care, we will no longer manage chronic pain” as Mass. patient is told he will “taper off” in 1-2 months: I don’t know the clinic. I know the trend lines reflect impact of making a liability (the patient) unbearable.
2/The overprescribed opioids’ role in contributing to problems of diversion & overuse drew a controlling reaction in which the Rx itself was seen as the prime target for reduction, by nearly all parties that could- simultaneously- affect prescribers’ sense of safety to practice
3/Amidst #COVID19 – neither a urine drug test nor an in-person visit are strictly required by existing DEA rules, but DEA rules alone don’t determine the decision framework for prescribing clinicians deadiversion.usdoj.gov/GDP/(DEA-DC-02…
4/Clinicians have absorbed a collective message that situates them as “potential bad actors”. They are reacting, in part, to metrics such as
- “% of patients at risk of continuing on long term opioids”
- “% of patients receiving opioids at high dose”
5/Note: the warnings issued in 2017 about how these metrics would affect patient care were specific, shared with the very top decision makers, signed by people who worked on @CDCgov guideline, and the outcomes were just as bad as predicted medium.com/@StefanKertesz…
6/The outcomes papers do not tell a simple, causal story. But #opioid stoppage slow or fast, by clinics deciding that they can’t handle the pressure has not been shown to be safe.The papers of 2019-20 require another thread. All show clinical instability –
7/But the story can be understood 3 ways.
Analytically, as a “de-implementation” failure, where collision of a crisis, litigation, some good will,lack of understanding of pain care & a toxic environment helped drive clinicians away from vulnerable patients link.springer.com/content/pdf/10…
8/From a policy view, tacit acceptance that patients suffer harm as we “taper off”or”shut off” involves suspension of a customary norm in healthcare:leaders hold themselves accountable for harms,study them, and act decisively to stop them-That’s my @TEDx
9/Before the 3rd view, let me counter an occasional misinterpretation of my work. I never say all opioid reductions “caused harm” or there is “no benefit” to a more cautious #opioid Rx use. They are not magic, but problematic.
10/The 3rd way to understand how clinical practices can close off a large categories of patients, who receive #opioids, is that the policies put into play nationally, and the documents they cite, routinely discount the views of patients with pain, whose lives are affected.
11/On a more hopeful note: in 2019, 3 federal agencies (HHS, CDC, FDA) drew attention to harms observed from various improper invocations of CDC’s guideline. And a recalibration has been ongoing in some settings blogs.bmj.com/bmj/2020/03/03…
12/ my Rec’s:
- individualize care to combine evidence, clinical conditions, context & preferences
- ”opioid safety” work should be retooled as protecting _patients_ with complex illness rather than making _opioids_ safe
- get patient/family views at every policy step
Opioid metrics dismiss medical concerns and discourage doctors from using their professional judgment and experience ando make them legally liable for any deviation from standardized protocols.
No wonder so many are leaving the profession (or committing suicide)!