Tag Archives: standards

CDC Guideline Harms Pain Patients

CDC Guideline Harms Pain Patients, Panel Saysby Judy George, Contributing Writer, MedPage Today – March 11, 2019

The CDC’s 2016 opioid guideline is being implemented in ways that harm chronic pain patients, a panel of physicians said here.

I agree that the problem isn’t with the guidelines themselves.  They were just

1) suggestions,
2) for primary care providers and
3) first-time opioid prescriptions.

The problem is that they have been weaponized by anti-opioid crusaders to make laws and rules that force opioid tapers even when not medically indicated.  Continue reading

Reducing the global burden of chronic pain

Reducing the global burden of chronic pain – Beth D. Darnall, Clinical Professor, Stanford University School of Medicine

The profound global burden of chronic pain is increasing as the world population ages, and particularly so for low and middle income countries.

Reducing the global burden of pain requires

  • national policy and investment to develop coordinated local, national and international efforts to improve professional and public pain education;
  • promotion of the biopsychosocial model of evidence-based pain care;

However, the biopsychosocial model is based on poor or biased evidence. Many pain patients ultimately respond only to the effectiveness of opioid therapy.  Continue reading

Medical guidelines may be biased, overly aggressive

Medical guidelines may be biased, overly aggressive in USCornell University – Apr 2019

Dr. Sunita Sah practiced general medicine for several years in the United Kingdom’s National Health Service. When she came to the United States, she noticed something strange.

The U.K. guidelines for tests such as mammograms and colon cancer screenings drastically differed from those in the U.S…

…even though they were based on the same medical evidence.   Continue reading

Inconsistent Definitions of Opioid Use Disorder

Agreement between definitions of pharmaceutical opioid use disorders and dependence in people taking opioids for chronic non-cancer pain (POINT): a cohort study – The Lancet Psychiatry – free full-text – Mar 2015

Background

Classification of patients with pharmaceutical opioid use disorder and dependence varies depending on which definition is used.

I find it outrageous that OUD can be diagnosed on a whim just by using the fitting definition in one of the several classification systems.

The DSM-5 is the worst, thanks to its “spectrum” of Opioid Use Disorder (OUD), which always places us pain patients, with our regularly prescribed opioids, into the low end of this spectrum.  Continue reading

The fallacy of patient-centered care

The fallacy of patient-centered care– KevinMD.com – by – Mar 2019

According to NEJM CatalystPatient-and family-centered care encourages the active collaboration and shared decision-making between patients, families, and providers to design and manage a customized and comprehensive care plan

Under patient-centered care, care focuses more on the patient’s problem than on his or her diagnosis. Patients have a trusted, personal relationship with their doctors …”

Historically, patients have had better relationships with their physicians than they do today.    Continue reading

A patient’s opposition to the anti-opioid movement

A patient’s opposition to the anti-opioid movement – KevinMD.com – Mar 2019

I wrote this essay for the doctors’ blog, KevinMD.com. My original title was “California’s Death of Sanity Project” as I criticize what’s called the “California Death Certificate Project”.

It’s bad enough that they are prosecuting doctors for prescription they are writing now, but this project goes up to three years into the past, looking for any opioid prescription to a person who overdoses, even years after they received the prescription, even if the overdose was from fentanyl or a combination of multiple illicit drugs.

As I end my essay:

Trying to stem illicit opioid overdose deaths by mandating restrictions on opioids for patients in pain is only a cruel experiment fueled by ignorance and fear.

— Read on www.kevinmd.com/blog/2019/03/a-patients-opposition-to-the-anti-opioid-movement.html

Our health info bundled into simplistic “risk scores”

How your health information is bundled into a “risk score” – Twitter thread by Stefan Kertesz – @StefanKertesz – comment on previous Politico story.

1/How your health information is sold and turned into ‘risk scores’ – from @politico …Let me share a couple insights from using a risk tool paid for by US taxpayers https://www.politico.com/story/2019/02/03/health-risk-scores-opioid-abuse-1139978

2/First, risk scores of high quality use all health information, as VA studies show risk for OD/suicide reflects

(a) medical + mental + prior substance use, &
(b) # of co-prescribed sedating mess that are crucial.

Actual #opioid dose, formulation are relevant, but less so

https://twitter.com/StefanKertesz/status/1092266758436802560/photo/1 Continue reading

Our health information sold and turned into ‘risk scores’

How your health information is sold and turned into ‘risk scores’ – politico.com – By MOHANA RAVINDRANATH – Feb 2019

Companies are starting to sell “risk scores” to doctors, insurers and hospitals to identify patients at risk of opioid addiction or overdose, without patient consent and with little regulation of the kinds of personal information used to create the scores.

Over the past year, powerful companies such as LexisNexis have begun hoovering up the data [what ever happened to HIPPA?] from

  • insurance claims,
  • digital health records,
  • housing records, and
  • even information about a patient’s friends, family and roommates,

without telling the patient they are accessing the information, and creating risk scores for health care providers and insurers.   Continue reading

Switching Opioids for Better Pain Relief

Could Switching Opioids in Cancer Patients Provide Relief? – Lori Smith, BSN, MSN, CRNP – Nov 12, 2018

I’m disappointed to see this limited only to cancer patients. Since we know that there’s NO DIFFERENCE between cancer and non-cancer pain, these findings would also apply to other kinds of chronic pain.

Side effects and inadequate pain relief with the use of opioids in cancer patients is a challenge for healthcare providers to manage and can cause considerable problems for these patients.

While the topic is still debated within the medical community, opioid switching in cancer patients may provide relief of pain and alleviation of opioid-related side effects, according to the results of a recent Italian study.   Continue reading

We Need Patient-Centric Opioid Prescribing Guidelines

The Importance Of Patient-Centric Opioid Prescribing Guidelines – forbes.com – by Joshua Cohen – Aug 2017

In light of an opioid crisis that has claimed tens of thousands of lives, health authorities and regulators have attempted to reduce the number of opioids prescribed to patients by forced tapering or the institution of quotas.

While the U.S. Centers for Disease Control and Prevention (CDC) advocates tapering and, in some cases, discontinuing opioids in patients who have used using them as long-term therapy for non-malignant chronic pain, it purposely designed its guideline as non-mandatory

Guidelines are, by definition, not mandatory; they are simply guidelines, however…

They can be used to make rules establishing their suggestions as absolutes. I’m sure the guideline authors (mostly PROP members) knew this is exactly what would happen with opioid prescribing.

Additionally, it absolves them of guilt for the atrocities inflicted on chronic pain patients in the name of their “non-mandatory” guidelines, which have predictably been weaponized as hard limits on dosages.

However, a number of legislators, pharmacies, and payers have perhaps misinterpreted the recommendations and turned them into compulsory limits and quotas.

In certain instances, mandatory opioid tapers may do more harm than good, medical experts warn in a letter published in the journal Pain Medicine.

The letter states that “rapid forced tapering can

  • destabilize patients,
  • lead to a worsening of pain,
  • precipitate severe opioid withdrawal symptoms and
  • cause a profound loss of function.”

Obviously, reducing misuse is an appropriate objective. But, the means to do so ought to reflect a balanced approach of risk management, rather than blunt instruments, such as a blanket policy of compulsory tapering or the institution of mandatory opioid quotas.

…according to Dr. Joanna Starrels, an opioids researcher and associate professor at the Albert Einstein College of Medicine “the decision to taper opioids should be based on whether the benefits for pain and function outweigh the harm for that patient.

A case-by-case approach is warranted, she says, as each decision “takes a lot of clinical judgment. It’s individualized and nuanced.

We can’t codify it with an arbitrary threshold.

But that’s exactly what has happened in this country, despite the CDC’s insistence to the contrary: Opioid Guidelines Not a Rule, Regulation or Law.

And it’s not even addressing the problem it is intended to rectify:

According to Dr. Marcia Angell, the “overwhelming majority of deaths are caused not by opioids such as OxyContin, but by combinations of fentanyl, heroin, and cocaine. … frequently taken along with benzodiazepines and alcohol.”

The letter published in Pain Medicine calls for a patient-centered approach of “compassionate systems for opioid tapering” in carefully selected patients, with close monitoring and realistic goal

Notably, in 2016, the CDC laid the groundwork for risk stratification in its guidelines on opioid prescribing. In that guidance, the CDC outlined a nuanced, patient-centric view on opioid prescribing.

Namely, patients who present at the physician’s office with chronic pain should be assessed individually for their actual need for opioids versus non-opioid or even non-pharmacologic treatment, as well as key factors gleaned from a patient’s risk profile.

In other words, rather than automatically matching pain levels to specific doses of an opioid or other analgesic, physicians are advised in the CDC guideline to tailor treatment following a thorough evaluation of each patient that includes a review of tolerance for pain, subjective preferences for treatment, and risk of misuse, abuse, and diversion.

So why isn’t anyone enforcing this part of the guideline?

Forced tapers across the board go directly against this stated guideline to “tailor treatment following a thorough evaluation of each patient”, but no one is pushing for such individualized treatment.

Nor are they pointing out that the guideline was intended ONLY for primary care physicians and ONLY for initiating new opioid therapy.

Nor is the CDC doing what they said they would: studying and evaluating the outcomes of this bomb they dropped.