STAT News: Chronic Pain Quandary Amid a Reckoning of Opioid Overdoses...

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drusso

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"When Kertesz thinks, he leans forward and pulls his hair back. His obsessive streak extends to both his career and his personal life. (He’s become a fencing fanatic, having taken up the sport less than six years ago.) When he talks about medicine, he pauses mid-conversation to point out whether his statements are based on randomized trials or his own inference. He can appear scatterbrained and is working with a coach to become more structured."

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The line between cool and eccentric vs nutjob. Goal is to stay on one side of line, and not the nutjob side of it. If only Rickon could serpentine as he ran away from Ramsey as well as Kertesz does across that line.
 
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Kertesz appears to promote tapering as long as the patient does not object to opioid tapering. This means that no one that needs to be tapered will actually be tapered. Very few chronic pain patients on high dose opioids ever want to be tapered off opioids, due to fear of hyperalgesia, opioid withdrawal syndromes, and chemical and psychological dependence on the drugs. Some do not want to be tapered because use of opioids validates their disability behaviors and because of fear of losing their disability income.
 
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in his prior statements, where he stated that tapering was almost never indicated.

again, he is an internal medicine addiction doctor who as far as one can tell has never written a single Medicare prescription and probably no prescription outside of the Alabama VA, notorious for being one of the 2 highest opioid prescribing VAs in the country...


fwiw, if Rickon lived, no Battle of the Bastards, Ramsay wins battle, takes over the North, allies with the Night King, marries Cersei and we have Season 9...
 
in his prior statements, where he stated that tapering was almost never indicated.

again, he is an internal medicine addiction doctor who as far as one can tell has never written a single Medicare prescription and probably no prescription outside of the Alabama VA, notorious for being one of the 2 highest opioid prescribing VAs in the country...


fwiw, if Rickon lived, no Battle of the Bastards, Ramsay wins battle, takes over the North, allies with the Night King, marries Cersei and we have Season 9...


Hello- I am glad to be in conversation if you wish. I do not know why but some folks on Twitter tweeted your comments. If you have questions, share them.

In terms of where I have worked, there is no need to speculate.

I trained at Beth Israel Hospital in Boston, worked full time and later part time at Boston Health Care for the Homeless Program (1996-2002), while attending on faculty at BU, and training there in a fellowship that emphasized addiction/primary care and service design.

Later in Alabama I worked in a university hospital, a federally qualified health center and the Veterans Administration. There are many differences in care by state and system. But the concerns I raise are ones that have drawn concern of clinicians and non-clinicians in other settings and many states.

My research, funded by NIH and VA variously, relies on multidisciplinary teams from other states

Whatever is the “Alabama angle” (and I am glad to chat about that; it certainly is a high prescribing state), the core concerns are not unique to a state.

Anyway, feel free to send or post questions

Stefan
 
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Hello- I am glad to be in conversation if you wish. I do not know why but some folks on Twitter tweeted your comments. If you have questions, share them.

In terms of where I have worked, there is no need to speculate.

I trained at Beth Israel Hospital in Boston, worked full time and later part time at Boston Health Care for the Homeless Program (1996-2002), while attending on faculty at BU, and training there in a fellowship that emphasized addiction/primary care and service design.

Later in Alabama I worked in a university hospital, a federally qualified health center and the Veterans Administration. There are many differences in care by state and system. But the concerns I raise are ones that have drawn concern of clinicians and non-clinicians in other settings and many states.

My research, funded by NIH and VA variously, relies on multidisciplinary teams from other states

Whatever is the “Alabama angle” (and I am glad to chat about that; it certainly is a high prescribing state), the core concerns are not unique to a state.

Anyway, feel free to send or post questions

Stefan

Welcome @skertesz . It would be wonderful to have your perspective on some of the contentious opioid-related topics we discuss here. We're quite an eclectic group with hundreds of years of collective experience between us.

Personally, I've always wondered how COI influence the discussions and policy-making in opioid-related matters--not just in the traditional sense of being paid by Pharma to RX drugs--but more subtlely too: Academics who advance their career and reputations writing guidelines or re-hashing GIGO science; ideological COI about whether or not chronic pain or addicts are "worthy" patients to treat in the first place, ideological COI about population-based versus patient-centered approaches to care and it's delivery, etc. We've had intense discussions on these topics here over the years.

To get caught up and get a sense of where people are coming from, I suggest you start here:

 
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I think the summary from PROP- dated 2012- is a reflection of part of the story. A necessary reality is that my own advocacy is only sensible after taking seriously the case made in those slides (I am saying to be prudent about what we do in the wake of recognizing a crisis due to culture of excess prescribing). It is not clear that my arguments to the public would have a utility or a value if we had not absorbed the lessons that excess pill prescribing caused harm. The challenge is how to see that original fact and not oversimplify in ways that lead to care changes that are untethered to data or evidence.
 
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I think the summary from PROP- dated 2012- is a reflection of part of the story. A necessary reality is that my own advocacy is only sensible after taking seriously the case made in those slides (I am saying f be prudent about what we do in the wake of recognizing a crisis due to culture of excess prescribing). It is not clear that my arguments to the public would have a utility or a value if we had not absorbed the lessons that excess pill prescribing caused harm. The challenge is how to see that original fact and not oversimplify in ways that lead to care changes that are untethered to data or evidence.
In regard to conflict of interest- I think we should start from the premise that everyone has some interest of some kind and the question is to make sure you interrogate how that interest might lead the speaker to ignore evidence, or to fail to provide it, or to discount reasonable questions about it. Monetary interest is a substantial interest, but intellectual preconceptions and “reputations aggrandizement” are all reasonable to ask about.

I confess with myself I have a long term interest in care of multi-morbid highly vulnerable populations who often receive a skeptical or hostile treatment in health care.

Homelessness and the complex web of social addictive and physical conditions associated with that vulnerability are my core interest. Pain is prevalent in that population.

Opioid policy intersects, obviously
 
thank you for coming on. now all we need is for 101N to come back to have a balanced forum.


the problem I see is that it is easy to post a position - be it PROP or pro-opioid - that is misrepresented and misconstrued by general public. I argue that positions that are truly pro-opioid lead many chronic pain patients to believe - based on not only what they are hearing but their own self-interests - that opioid therapy is the one and only therapy that is going to be beneficial. this is what I see in my clinical practice, which is tragically heavy in the "vulnerable" population - both from a health perspective and from an insurance one.

My overall clinical experience with the chronic pain population is that there is an unhealthy fixation with maintenance of chronic opioid therapy, and initiation of opioid therapy is more dangerous than the underlying initial reason for initiation of therapy. our societal expectation is currently that opioid therapy is a treatment for poor quality of life, and that in my opinion is a dangerous and false connection.

the overall tenor of the articles appear to imply that patients on chronic opioid therapy should never be tapered without their direct consent. im not sure if this was your intention.

a corollary, not directly related to this implication, is that patients have the right to self-determine whether to start opioids in the first place.
 
thank you for coming on. now all we need is for 101N to come back to have a balanced forum.

Remember, 101N didn't leave voluntarily. He suffered TOS infractions--especially 5,4,3, and 2. You don't want @skertesz to emulate him.

 
DOODOOCSS so insightful as usual
 
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