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Friday, August 18, 2017

The "opioid epidemic" and the EHR

From The New Yorker (my new hardcopy arrived in the snailmail today):
"...the President pointed out, again, that once a person starts using drugs it is “awfully tough” to get him off, but suggested that the problem might be avoided by telling young people that drugs are “no good, really bad for you in every way.” His wife, Melania, sat beside him, as if to echo Nancy Reagan’s support of the “Just say no” campaign during her husband’s Administration. But that message seems particularly inappropriate, given the epidemiology of this drug crisis: the first person many addicts would have to say no to is a health-care provider…"

Certainly getting a ton of media coverage across the last year or so. I can't claim to have done any deep study here going to the prevalence and incidence trends of late with respect to opioid class Rx adversity. But, particularly in light of the President's (typically) confused assertion above, I do worry about (ulterior motive?) "conflation" -- "the first person many addicts would have to say no to is a health care provider" -- i.e., illegal street drugs vs. inappropriately, overused nominally legit Rx. As I reported in 2015,

I've had my own issues with proper "pain management" Rx obstruction:
...Tramadol 50 mg. I have some bulging disks and pinched nerves ("cervical and lumbar spondylosis with myelopathy"), in part the upshot of too many years of getting the crap knocked out of me while pursuing my absurd decades-long full-court Hoop Dreams, (I have the attestational eyebrow suture scars, and torn meniscal and MCL vestiges), followed by too many recent years of too much sitting, reading, and blogging for hours and days on end.

I usually took one Tramadol a day, in the early morning upon arising (even though the scrip said 'one every 4-6 hours as needed'). On bad days, I'd drop a 2nd one mid-day. They helped. Materially.

Given that DEA recently "rescheduled" Tramadol, I can't help but wonder whether my young doc wants to keep his fingerprints off the Rx. I'd given him my entire longitudinal Hx from my Vegas Primary, dumped from the EHR. I fail to see the point of doing an expensive encounter with yet another physician -- one who doesn't know me, and who will have to redundantly (and expensively) read the chart, listen to (or blow off) my CC Subjective, and either bless or deny the simple Rx request...
My current Muir Primary writes me for Meloxicam. 1x/day.

Works acceptably (if not quite as well). It's a NSAID, not an opioid. I'm largely over my irascible Tramadol snit.

More from The New Yorker piece:
During the 2016 Presidential campaign, when Donald Trump was asked about the opioid crisis he often mentioned that he first learned about the severity of the situation in New Hampshire, which he visited several times ahead of that state’s primary. In 2014, after West Virginia, New Hampshire had the second-highest rate of death from opioid and heroin overdoses, at twenty-two out of every hundred thousand residents. (In 2015, there were more than thirty thousand such deaths nationwide, and the rate is projected to rise.)

As Trump heard more about addiction, he began speaking about it at rallies and, sometimes, in personal terms. Five days before the New Hampshire primary, at an event in Manchester, Trump talked about his older brother, Fred, who died in 1981, following a long battle with alcoholism. “He had everything,” Trump said. “I mean, the most handsome guy. And then he got hooked and there was nothing—and by the way, nothing you could do about it.” A woman sitting behind him nodded in agreement, as others in the room listened, rapt. Yet, as much as people empathized with Trump’s conclusion that he was, on an individual level, powerless in the face of his brother’s addiction, some of them voted for him because he also claimed, with increasingly sweeping rhetoric, that he, and perhaps only he, could “solve” the national crisis.

Last Tuesday, the President attended a “major briefing” on the epidemic with the Secretary of Health and Human Services, Tom Price, and other aides, at his golf club in Bedminster, New Jersey. They had with them a draft report that had been prepared by a special commission chaired by Governor Chris Christie, of New Jersey. The draft is rich in recommendations for channelling additional resources to the crisis. One is that naloxone, an anti-overdose drug known commercially as Narcan, be provided to first responders at a lower cost. Another would expand the definition of the kinds of in-patient facilities that are eligible for reimbursement under Medicaid, which the authors say is the quickest way to get help to a large number of people. In fact, the report demonstrates the crucial role that Medicaid plays in addressing the crisis, and the program’s still greater potential for combatting it. (The report also helps explain why Senator Mitch McConnell had a hard time getting colleagues from states hit hard by opioids to sign on to an Obamacare repeal that called for gutting Medicaid.)

Trump, however, gave no sign of rethinking his approach to funding these public-health initiatives. Instead, before he upended the briefing with his threat to consume North Korea with “fire and fury,” he had focussed his remarks on finger-pointing and punitive measures. The opioid crisis, he said, is the fault of the Mexicans and the Chinese, who allow drugs to be sent from their nations to ours. The metric that he offered for success in handling the problem domestically was the number of federal drug prosecutions brought and the average length of prison terms they produced. Both have dropped since 2011, which the President sees as evidence not of a bipartisan consensus on the need for sentencing reform but as proof of the laxity and the bad faith of members of the Obama Administration, who, he said, had “looked at this scourge, and they let it go by.”

Attorney General Jeff Sessions has already instructed federal prosecutors to pursue charges yielding the maximum possible prison terms, and revoked earlier guidelines designed to avoid harsh mandatory minimum sentences in cases involving nonviolent drug offenders. This promises to expand the practice of mass incarceration, with people cycling in and out of prison without receiving treatment, and further generations of children being exposed to disruption, broken families, and, potentially, their own susceptibility to what painkillers seem to offer.

At the briefing, the President pointed out, again, that once a person starts using drugs it is “awfully tough” to get him off, but suggested that the problem might be avoided by telling young people that drugs are “no good, really bad for you in every way.” His wife, Melania, sat beside him, as if to echo Nancy Reagan’s support of the “Just say no” campaign during her husband’s Administration. But that message seems particularly inappropriate, given the epidemiology of this drug crisis: the first person many addicts would have to say no to is a health-care provider…
"Marijuana is an extremely dangerous drug ... Good people don't smoke marijuana."
This ignorant cracker never fails to raise my BP. To him, potentially dangerous overmedication problems are likely simply seen as law enforcement problems. For which, perhaps for-profit private prisons might be of assistance.

apropos, I have some distant tangential scholarly history on this topic. From my 1998 graduate thesis (on coercive mass drug testing):
...our government “finds,” on the basis of myriad reports—derived principally from news stories and social science investigative methods of wildly variant quality—that the use of illicit drugs, particularly in the workplace, is a sufficiently adverse social and economic phenomenon to justify the coerced participation of millions of asymptomatic citizens as “donors” of bioassay specimens for chemical metabolite analysis to uncover the presence of forbidden psychoactive recreational toxins. Willing, even eager submission to non-cause drug testing is coming to be seen as the latest variant of the Loyalty Oath, with aspersions cast upon the motives and character of dissenters. Legions of survey researchers provide an endless outpouring of statistics purporting to demonstrate the alarming prevalence and horrific economic and epidemiological costs of drug abuse. Vendors of laboratory services assure us that their technologies are utterly reliable, that only the “guilty” need be concerned. It’s For Our Own Good, we are soothingly told.

Is any of this so? Are the enabling laws and policies ethical and wise, grounded in coherent history and viable scientific data? Are such measures critical to public health and safety? Are the analytical procedures and technologies truly effective, and fail-safe to the point of negating reasonable concerns over the possibility of false accusation? Can the nation’s laboratory infrastructure deal competently with the already huge and rapidly increasing sample workload? Is such a forcible deterrence strategy the only feasible option available to us for promoting the health and welfare of both individuals and society as a whole?

The questions are timely ones. A spate of expansive and harsh new drug testing legislative proposals is under consideration by the 105th Congress and state legislatures around the nation, and commercial vendors of analytical technologies are rushing to market patented (and, as such, potentially enormously lucrative) alternatives to the conventional urine and blood tests traditionally used in drug bioassay. There now exist methods that use hair and saliva samples, as well as a recently introduced “patch” that, when worn on the skin, ostensibly reveals the presence of illicit compounds. Also recently in the news were reports on the commercial availability of a $20 drug testing “smear kit” called DrugAlert™ that parents are being encouraged to use on their childrens’ clothing, furniture, and possessions if they suspect their kids of drug use. The kits are returned to the vendor for analysis, after which a “confidential” report of findings is mailed back to the parents.

How did we arrive at such a state of alarm? The path leading to proposals for a panoptic metabolite surveillance state is a perplexing one...
We have learned nothing.

Welcome to Trump's "Just Say No" v2.0.
Trump Declares National Opioid Emergency (August 12th)

President Trump declared the opioid crisis a "national emergency" on Thursday, after declining to do so during a press briefing two days prior.

An advisory panel had urged the president to declare an emergency in an interim report last week.

"The opioid crisis is an emergency, and I'm saying officially right now it is an emergency. It's a national emergency. We're going to spend a lot of time, a lot of effort and a lot of money on the opioid crisis," he told USA Today and other reporters during a press briefing.

Asked whether Trump needed "emergency powers" to make such a declaration, the president responded, "We're going to draw it up and we're going to make it a national emergency. It is a serious problem, the likes of which we have never had."

Physicians, policy experts, and health consultants reacted positively to the news of the Trump administration's decision to declare the opioid epidemic a national emergency. But what the President does next will determine how successful his efforts are, they suggested…
No details thus far on what will comprise an actual constructive, effective action plan.

So, looking down in the eRx data tables of every doc's EHR documentation, can we expect DOJ subpoenas? Or, short of that, Big Brother HHS gumshoeing of eRx transactions via online PBM intermediaries such as SureScripts?

To the extent that the escalated opioid Rx abuse incidence represents an exigent "national emergency," we will not arrest and prosecute our way out of it.


apropos of my last assertion, I saw an interview with this Stanford addiction med physician on MSNBC last night.

"Three out of four people addicted to heroin probably started on a prescription opioid, according to the director of the Centers for Disease Control and Prevention. In the United States alone, 16,000 people die each year as a result of prescription opioid overdose. But perhaps the most frightening aspect of the prescription drug epidemic is that it’s built on well-meaning doctors treating patients with real problems.
In  Drug Dealer, MD, Dr. Anna Lembke uncovers the unseen forces driving opioid addiction nationwide. Combining case studies from her own practice with vital statistics drawn from public policy, cultural anthropology, and neuroscience, she explores the complex relationship between doctors and patients, the science of addiction, and the barriers to successfully addressing drug dependence and addiction. Even when addiction is recognized by doctors and their patients, she argues, many doctors don’t know how to treat it, connections to treatment are lacking, and insurance companies won’t pay for rehab..."
She proffered my very same point. (Disclosure; I've not bought and read this book. I may.)

BTW, recall my post of several years ago, on the book "Overdo$ed?"

Oh, uh, tangentially, from Naked Capitalism:
How Alfred McCoy Stalked the CIA From Its Heroin Trail to the Surveillance State
Posted on August 25, 2017 by Yves Smith
Some People Still Need Opioids
The crackdown on pain medication prescribing is intended to help the addiction crisis—but it’s leaving chronic pain patients in untenable situations.

On July 26, Todd Graham, 56, a well-respected rehabilitation specialist in Mishawaka, Indiana, lost his life. Earlier that day, a woman complaining of chronic pain had come to Graham’s office in hope of receiving an opioid such as Percocet, Vicodin, or long-acting OxyContin. He reportedly told her that opioids were not an appropriate first-line treatment for long-term pain—a view now shared by professionals—and she, reportedly, accepted his opinion. Her husband, however, became irate. Later, he tracked down the doctor and shot him twice in the head.

This horrific story has been showcased to confirm that physicians who specialize in chronic pain confront real threats from patients or their loved ones, particularly regarding opioid prescriptions. But Graham’s death also draws attention to another fraught development: In the face of an ever-worsening opioid crisis, physicians concerned about fueling the epidemic are increasingly heeding warnings and feeling pressured to constrain prescribing in the name of public health. As they do so, abruptly ending treatment regimens on which many chronic pain patients have come to rely, they end up leaving some patients in agonizing pain or worse…
My gravely ill daughter would be in abject, unbearable misery but for the morphine and MScontin she takes daily.

A doctor’s murder over an opioid prescription leaves an Indiana city with no easy answers

MISHAWAKA, Ind. — Dr. Todd Graham wasn’t yet halfway through his workday at South Bend Orthopaedics when a new patient came into his office here complaining of chronic pain.
Heeding the many warnings of health officials, he told her opioids weren’t the appropriate treatment.

But she was accompanied by her husband, who insisted on a prescription. Graham held his ground. The husband grew irate. The argument escalated to the point that Graham pulled out his phone and started recording audio until the couple left.

Two hours later, the husband would return, armed.

Graham didn’t know that the shouting in his office wasn’t the end of the confrontation. It was frightening, he told his colleagues. But the incident two weeks ago wasn’t out of the ordinary — physicians here and across the country have grown increasingly accustomed to disputes over opioids. So Graham didn’t call the police. He didn’t file a report. He just kept seeing patients.

Many of his peers say they would’ve done the same thing. Many of them have.

Now, they’re not so sure.

That’s what they whispered to one another at the funeral five days later — the funeral for Dr. Graham…

As a tangential aside, I'm reminded of an Ann Neumann's obervation on a nexus involving law enforcement and pain mangement.
Pain management in a facility where drug use is rampant— and, indeed, a major cause of incarceration— is problematic. Doctors and nurses can find it hard to believe a patient who tells them he’s in pain. “A culture of suspicion emerged concerning the illicit drug trafficking of narcotics intended for pain relief,” the Palliative Medicine report states. The “macho” prison culture also prevented many in pain from admitting what they felt. But a larger issue, one difficult to measure, exists: “prison healthcare staff may believe that prisoners deserve their suffering.” In other words, pain is punishment. Staff members tend to default on the side of pain when prescribing narcotics to hospice patients. If anyone deserves to be in pain, the thinking goes, don’t thieves, murderers, drug users, rapists? In church parlance and even in broader society, the belief that pain makes us better people is commonplace. In prison, suffering is part of the centuries-old plan.

Neumann, Ann. The Good Death: An Exploration of Dying in America (p. 170). Beacon Press. Kindle Edition.

From STATnews:
New tool helps physicians learn if their opioid prescribing is appropriate

Addiction is a powerful, complicated disease. Genetic, environmental, and psychosocial characteristics all factor into a person’s risk for dependency. When it comes to opioid addiction, who your doctor is also influences whether or not you will become addicted to these powerful pain medications.

That’s because some doctors write opioid prescriptions more often, and for longer, than other doctors. Taking opioids for just five days — days, mind you, not weeks or months — can lead to long-term use and addiction. So when a doctor writes an initial prescription for nine days instead of three, that doctor is increasing his or her patient’s risk of opioid addiction.

Of course, there are many people who need opioids for pain management and for whom opioids are a legitimate treatment option. But easy availability and a lack of appreciation for the true risk of addiction have contributed to the opioid epidemic. We need to curb overprescribing to loosen opioids’ grip on America. But when it comes to opioids, many physicians don’t have a good sense of what constitutes appropriate use. Helping physicians navigate this minefield is an important next step in controlling the nation’s opioid epidemic…
Our initiative is focused on bringing transparency to opioid prescribing behavior in a way that does not threaten the doctor-patient relationship. Instead, we are giving physicians the data they crave to understand their own and their peers’ practice patterns. This approach of holding a mirror into physicians’ own practicing patterns has been shown to spark meaningful behavior change without bringing a physician’s clinical judgment into question.
This effort to develop appropriateness measures is an entirely doctor-developed, home-grown solution, one that uses the wisdom of clinicians to put actionable and relevant data into the hands of physicians. Doctors may have contributed — however unknowingly — to the current opioid crisis. And doctors can help bring us back from it.

More to come...

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