Anyone have the new CDC opioid draft?

[gaspasser127]

Anyone have the actual document? I only see a short summary or news articles about it online.

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[Ferrismonk]

I don't think they've released anything yet.

 

[drusso]

I don't think they've released anything yet.

CDC Newsroom

Press releases, advisories, telebriefings, transcripts and archives.

www.cdc.gov

They still haven't removed all the stains of COI from the 2016 guidelines. Too many taper KOLs laughing all the way to the bank...

 

[kstarm]

CDC Newsroom

Press releases, advisories, telebriefings, transcripts and archives.

www.cdc.gov

They still haven't removed all the stains of COI from the 2016 guidelines. Too many taper KOLs laughing all the way to the bank...

What financial incentives do they get for recommending tapering?

 

[Ferrismonk]

From what I can gather, they're in the information gathering stage, nothing released yet.

 

[drusso]

What financial incentives do they get for recommending tapering?

They're in it more for prestige, speaking fees, and career advancement. But some of these guys are bringing down Tim Deer dollars...

Testimony of ‘paid expert’ questioned by drugmaker | The Journal Record

An attorney representing Johnson & Johnson chipped away at testimony provided by an expert witness for the state Monday in a trial to determine whether J&J should be held responsible for fueling an epidemic of opioid addiction in Oklahoma.

journalrecord.com

"Yoder referred to Kolodny numerous times as the state’s “paid expert” and at one point asked the witness if he hasn’t been paid “substantially more” for his testimony than any of the so-called “key opinion leaders” who received fees from organizations funded in part by J&J to share opinions about benefits and risks associated with opioids. Kolodny confirmed that he had received several hundred thousand dollars in compensation for his time from various plaintiffs in claims against drug companies."

 

[lobelsteve]

Kolodny: hurting people for profit.

 

[lobelsteve]

They're in it more for prestige, speaking fees, and career advancement. But some of these guys are bringing down Tim Deer dollars...

Testimony of ‘paid expert’ questioned by drugmaker | The Journal Record

An attorney representing Johnson & Johnson chipped away at testimony provided by an expert witness for the state Monday in a trial to determine whether J&J should be held responsible for fueling an epidemic of opioid addiction in Oklahoma.

journalrecord.com

"Yoder referred to Kolodny numerous times as the state’s “paid expert” and at one point asked the witness if he hasn’t been paid “substantially more” for his testimony than any of the so-called “key opinion leaders” who received fees from organizations funded in part by J&J to share opinions about benefits and risks associated with opioids. Kolodny confirmed that he had received several hundred thousand dollars in compensation for his time from various plaintiffs in claims against drug companies."

Bone to pick with you drusso: one of your Regenexx boys in Atl gave my patient epidural or intradiscal prp. Post lami. Also induced him with Perc 10s and Valium. So is that part of your marketing?

 

[gaspasser127]

Full document available here:

 

[nvrsumr]

I dont have a dog in this fight but I think the CDC guidelines really helped out pain docs. So much easier to just say my hands are tied by the guidelines rather than arguing with patients about dose escalation. Plus its way easier on the mlps who are doing the prescribing anyway while the pain surgeons are in the OR.

 

[drusso]

Bone to pick with you drusso: one of your Regenexx boys in Atl gave my patient epidural or intradiscal prp. Post lami. Also induced him with Perc 10s and Valium. So is that part of your marketing?

I have no idea what you're talking about. Our facility infrequently uses sedation, but when we do it's usually like 50 mcg of FTN and 2 of versed for a kypho or SCS trial.

Can doctors do IV sedation in the office in Georgia?

 

[drusso]

I dont have a dog in this fight but I think the CDC guidelines really helped out pain docs. So much easier to just say my hands are tied by the guidelines rather than arguing with patients about dose escalation. Plus its way easier on the mlps who are doing the prescribing anyway while the pain surgeons are in the OR.

I'd like to see taper KOLs staying out of policy matters.

 

[Ferrismonk]

I dont have a dog in this fight but I think the CDC guidelines really helped out pain docs. So much easier to just say my hands are tied by the guidelines rather than arguing with patients about dose escalation. Plus its way easier on the mlps who are doing the prescribing anyway while the pain surgeons are in the OR.

Easier, yes. Appropriate? No.

Tell them the truth, there is little evidence opioids are helpful in chronic pain and there is good evidence of harm.

That being said, in my opinion, the CDC guidelines have been extremely helpful in changing the culture of opioid prescribing. Rarely do we get hit with the messes caused by PCPs "treating pain" by giving megadoses of Oxy 30 to everyone anymore. Also has been helpful codifying a standard MME equivalency and in stratifying overdose risk based on MME and concurrent medications.

 

[nvrsumr]

To be clear I put my money where my mouth is. Haven’t written a opioid script in 12 years. That was a rough decision to make when starting my solo practice. I could easily be wearing the pointiest of shoes otherwise.

 

[lobelsteve]

I have no idea what you're talking about. Our facility infrequently uses sedation, but when we do it's usually like 50 mcg of FTN and 2 of versed for a kypho or SCS trial.

Can doctors do IV sedation in the office in Georgia?

Yes. But your buddy here rx percs and valium for post op.

 

[drusso]

Yes. But your buddy here rx percs and valium for post op.

I wouldn't do that if I were him. Maybe a friendly call and collegial conversation from a colleague who consults with the Georgia Medical Board and other agencies could help...

 

[ctts]

I dont have a dog in this fight but I think the CDC guidelines really helped out pain docs. So much easier to just say my hands are tied by the guidelines rather than arguing with patients about dose escalation. Plus its way easier on the mlps who are doing the prescribing anyway while the pain surgeons are in the OR.

Easier, yes. Appropriate? No.

Tell them the truth, there is little evidence opioids are helpful in chronic pain and there is good evidence of harm.

That being said, in my opinion, the CDC guidelines have been extremely helpful in changing the culture of opioid prescribing. Rarely do we get hit with the messes caused by PCPs "treating pain" by giving megadoses of Oxy 30 to everyone anymore. Also has been helpful codifying a standard MME equivalency and in stratifying overdose risk based on MME and concurrent medications.

I tend to agree with nvrsumr...

I do also agree with Ferrmonk: "Tell them the truth, there is little evidence opioids are helpful in chronic pain and there is good evidence of harm."
But is that actually helpful in real life? I have tried to explain this to patient's but a patient who really wants their opioids is not going to change their mind because of that. They always say something along the lines of, "It may be true, but I can tell you that opioids help ME." Then what? Because of this dead end, it is hard to have a useful discussion with these particular patients...

I have had two patients this week bring up the new CDC update. One on opioids from PCP but not enough for him asking why I will not prescribe. Another I took over opioids from PCP, was supposed to be temporary, but of course turned into long term, asking why I need to taper her off. I do not have an answer that can satisfy them. Bringing me back to why I agree with nvrsumr.

 

[Ducttape]

if they ask for dose escalation, then tell them that if the meds are not helping, it is time to stop the medication altogether.

usually they will say "oh it does help a little bit, i just thought a little bit more would be more helpful."

to which you reply either "isnt that how we got to your present high dose?" or "what happens when you go up and you get used to that dose? thats called tolerance, and you will be stuck again."

another statement i have used: "you are at a dose that, if you had to find a new doctor to write the meds, you could possibly find someone. i cant recommend your PCP go up on the dosage, and it would be almost impossible to find another doctor to prescribe that dose. so i think you should be happy with what your doctor is willing to give you."

 

[kstarm]

Assuming the CDC rolls back the guidelines and removes the MME language. Will anyone change their practice approach?, do you think we will see PCPs escalating things or sending less patients for opioid management to pain clinics as their "hands won't be tied" any longer?

 

[drusso]

Assuming the CDC rolls back the guidelines and removes the MME language. Will anyone change their practice approach?, do you think we will see PCPs escalating things or sending less patients for opioid management to pain clinics as their "hands won't be tied" any longer?

I will follow the science.

 

[deleted131481]

I will follow the science.

What's the science for chronic opioid therapy?

 

[Ducttape]

i suspect PCPs will escalate again.

there is too much misinformation and too much push from non-prescribing KOLs who will push for high dose opioids again.

but its okay. most people will die from illicit fentanyl anyways.

What's the science for chronic opioid therapy?

very little.

 

[drusso]

i suspect PCPs will escalate again.

there is too much misinformation and too much push from non-prescribing KOLs who will push for high dose opioids again.

but its okay. most people will die from illicit fentanyl anyways.


very little.

The American Journal of Public Health (AJPH) from the American Public Health Association (APHA) publications

American Journal of Public Health (AJPH) from the American Public Health Association (APHA)

ajph.aphapublications.org

Knowledge Translation and the Opioid Crisis​

Jason N. DoctorPhD, and Mark D. SullivanMD, PhDAuthor affiliations, information, and correspondence details

Accepted: December 10, 2021

Published Online: February 10, 2022

Rapid solutions to the opioid crisis remain elusive. Prescriptions for opioids have decreased. Yet, supply limits have not reduced fatalities. Demand-side interventions have not fared any better. British Columbia, a place hit hard by the crisis, saw harm reduction at an all-time high in 2020. People there received 34 000 naloxone kits and filled 23 735 opioid agonist therapy prescriptions. Both are new records.1 However, there was a rapid rise in opioid-related deaths in 2020 compared with 2019 (1725 vs 985). A fentanyl-laced drug supply overshadows population health efforts. Because of this, changes in practice metrics have not guaranteed improvement in outcomes.

To address these concerns, Sud et al. (p. S56) discuss three types of translations of knowledge to improve outcomes. The first is to favor complex clinical interventions over simple population-based ones. They criticize educational programs, electronic health record prompts, and prescription drug–monitoring programs for focusing on population metrics without tracking clinical outcomes to ensure better success across implementations. Sud et al. view these interventions through a clinical lens. Yet, there is much more to them than can be measured from the standpoint of the identified patient. Although these interventions happen in a clinical setting, affect change in clinical care, and encourage best practices, patient outcomes will not capture the total social impact of opioid deprescribing. The primary benefit of fewer opioid prescriptions may be to families and communities. We know, for instance, that opioid prescriptions spread through households.2 One family member receiving an opioid prescription makes it more likely that another will get one. Judicious prescribing discourages household spread, a benefit not measurable at the patient level.

Opioid use predicts loss of pleasure and motivation even after controlling for pain severity, depression, and dosage.3 Through a loss of motivation, a community’s rate of opioid prescriptions may affect labor force participation: the rate of working-age people having or seeking employment. In early 2000, the labor force participation rate reached a maximum of 67.3%, and it has declined at a steady pace since then, reaching a 40-year low in September 2015 at 62.4%.4 Opioid prescriptions per capita increased by a factor of 3.5 nationwide between 1999 and 2015. A careful temporal analysis of county-level labor force participation between 2014 and 20164 linked to county-level opioid prescriptions nationally in 2015 found that county-level opioid prescriptions5 in 2015 accounted for 43% of the observed labor force decline.6

About half of prime-age men not in the labor force are on pain medication, and two thirds of these take prescription pain medications; these men report low levels of subjective well-being.6 It is likely that persons in prime age who are not in the workforce could benefit more from visiting a social worker for counseling than a physician offering pills. Other data indicate that county-level opioid marketing is associated with elevated overdose mortality one year later.7 Deprescribing interventions countervail community advertisements, impede the spread of prescribing through households, and may have positive effects on labor and the well-being of community members. Yet, these effects cannot be measured in a clinical setting.

Sud et al. would also like clinicians to factor population knowledge into smaller units that can translate into clinical effects. There are many clear examples. At clinic visits, it is safer for 10 people to receive 5 milligrams fewer than for one person to receive 50 milligrams fewer of an opioid. System rollout of psychological treatment of pain may fail to curtail opioid use because opioid use is appetitive. Buprenorphine orders may not rise when regulators remove administrative and legal burdens. This is because poor care coordination, clinician stigma, and lack of peer support are also barriers.8 In each case, population metrics may not do justice to the complexities in different local environments. The authors’ concerns seem right. And, although social benefits may be larger than clinical ones, without a careful implementation strategy, population-based interventions may fail altogether. With behavioral interventions, “details matter.”9 Interventions require a clinician’s attention and appropriate interpretation of information. For an intervention to work in a new clinic or system, each feature of the intervention must map in some proper way to the new environment. In the context of widespread drug stigma, how clinicians make sense of intervention is important. There needs to be careful attention to knowledge translation. An opioid taper should not be interpreted as an act of enforcement but as a collaboration with the patient.

Finally, Sud et al. describe a tendency in medicine to rank medical facts above patient values when approaching opioid tapering. They review studies that have documented the harms of opioid tapering but neglect to mention that most studies show that most patients improve with opioid tapering. They accuse Juurlink of construing the subjective benefits of long-term opioid therapy as illusory and less relevant than objective harms. Juurlink argues that “the goal of pain medication is not simpl[e] pain relief. Like any therapy, the goal is to confer more benefit than harm.”10(pe1222) He does not devalue the patient perspective. He simply does not want to limit the patient’s perspective to pain intensity ratings (a perspective that doctors have largely forced on patients). Patients’ ability to function at work, at home, and in relationships is also relevant.

Sud et al. also call for “epistemic humility”: “Chronic pain, as an inherently subjective condition, frustrates the core epistemology of clinical biomedicine that relies on evidence to objective pathology” (p. S61). We agree with this statement. Modern biomedicine seeks to explain subjective symptoms with objective tissue damage. It has also tended to dismiss “medically unexplained symptoms,” including pain, as not legitimately medical and likely psychological in origin. Yet modern pain research has revealed pain, especially chronic pain, to be a complex human experience with a loose and variable relationship to tissue damage. We agree that we should begin the clinical encounter by believing our patients’ reports of pain. But this is not because, as Sud et al. say, “[P]eople living with pain have unique epistemic access to their lives” (p. S63). The 17th-century French philosopher René Descartes argued that pain experience was incorrigible, but modern philosophy sees pain as interpersonal. We know a mother’s reaction has a direct effect on her child’s experience of pain.11 And, when clinicians help patients dispute chronic pain’s causes and threat value, both pain experience and brain processing change.12 This offers us new and effective means to treat the clinical and population problems of chronic pain.

Believing our patients’ reports of pain is only the beginning of our clinical responsibility to the patient with pain. Chronic pain has many causes—physical, psychological, and social—that must be investigated and addressed. Short-cutting this process by using a simple quantitative measure of pain intensity and seeking to reduce this number with opioid medication in accord with a claimed right to pain relief has brought us an opioid epidemic that has still not ended.

In sum, liberal opioid prescribing imposed a heavy cost on US communities and spawned a robust and toxic illicit market. Whether population-based interventions impose a cost on individuals, in the long run, is a worthy concern. However, this concern will be solved best by expanding mental health care, community support, and social service rather than turning our gaze back to increasing opioid prescriptions.