Monday, March 20, 2017

A Way to Fix a Drug Problem Without More Drugs?

Like many of my colleagues here at PRIUM and acquaintances outside of PRIUM who focus on chronic pain day in and day out, I get all manner of articles forwarded to me from friends about opioids and related medical treatment advances.  There's the spider venom that may hold the key to a more effective non-opioid painkiller.  There's the big-data, molecular-lottery approach that promises to identify medications capable of delivering pain relief without opioid side effects.  There's the on-going debate regarding medical marijuana's potential to stem opioid use.  This is just a sampling of the many studies, articles, ideas, and whims that appear in my inbox on a regular basis.

The theme that sticks out to me is the collective focus we seem to have on fixing a drug problem with more drugs.  

This reminds me of the unsettling moment at last year's National Prescription Drug Abuse and Heroin Summit here in Atlanta when Surgeon General Dr. Vivek Murthy offered some opening remarks prior to the arrival of President Obama at the conference.  In those remarks, he outlined a five-step strategy to combat prescription drug abuse and heroin and the first two steps were medication-based (#1 was expanding access to naloxone and #2 was expanding access to suboxone).  I think highly of Dr. Murthy and applaud his critical efforts to combat addiction in all its forms.  And I'm not even sure his plan isn't exactly what we need.  I was simply struck, again, by this theme of fixing a drug problem with more drugs.  It seems somehow counter-intuitive to me or, at least, not getting at root-cause issues.

So I was intrigued last week when I read about a study out of the University of Utah, Duke University, and Washington University in St. Louis.  The collaborating bioengineers have figured out a way to potentially manipulate our genetic code to suppress chronic pain.  For those rightly uncomfortable with the idea of messing with human DNA, the researchers are not editing or replacing genes.  Instead, they're using something called the CRISPR (Clustered Regularly Interspaced Short Palindromic Repeat) system to modulate the way genes turn on and off in order to protect cells from inflammation and tissue breakdown.  Early experiments point toward the possibility of eliminating the inflammation, cell death, and tissue damage associated with, say, low back pain caused by a herniated disc.  Sounds useful.  

Three quick observations:
1) This is at least 10 years away from human application.
2) Even then, it's not a panacea.  Surgery may still be required to fix underlying, biological causes of pain (though wouldn't it be nice to isolate that from non-biological, psycho-social contributors to pain?)
3) This work was funded by a National Institutes of Health grant, the likes of which could disappear if the current draft White House budget were to be adopted.

Michael
On Twitter @PRIUM1


Tuesday, March 7, 2017

What's Past is Not Prologue: Formularies Differ by State

I've recently heard predictions regarding California's forthcoming formulary that are based on the experience of Texas over the last five years.  Both are large states.  Both have well recognized, embedded utilization review processes.  And they have tertiary dispute resolution processes that, while not precise analogs, nonetheless look similar to one another (the Texas IRO process and the California IMR process).

So we might expect California, when it adopts it's drug formulary on or about July 1, to exhibit behaviors and results that are similar to the results Texas has achieved with its formulary (see my colleague Mark Pew's recent blog posts for insight into the CA timeline).  In Texas, prescriptions for "N" drugs fell by 81% and the costs for those same drugs dropped by 80%.  Total opioid scripts dropped by 8% and total drug costs in the state's work comp system fell by 15%.  All of this occurred with no discernible increase in loss adjustment expense (primarily, utilization review). So we might expect the same from California, right?  

I don't think so.  I offer three key data points in defense of that view:

First, the formularies are not the same.  Texas relies on Work Loss Data Institute's Official Disability Guidelines, Appendix A (which lists medications are either "N" or "Y" based on whether they are recommended for first-line therapy).  California has used as its starting point Reed Group's MDGuidelines in order to incorporate a formulary into MTUS.  The list of "non-preferred" drugs in these guidelines is a different, and frankly more restrictive, list than the ODG list of N drugs.  For instance, ODG has some opioid analgesics in the "Y" category.  The MDGuidelines categorized all opioid analgesics as "non-preferred." The two organizations take different approaches and I'm careful to avoid expressing preference for one or the other (PRIUM works closely with both sets of guidelines).  The important take-away here is that the two states are relying on different formulary approaches.

Second, about 38% of CA's lost-time claims have attorney representation.  That number for TX is 6%.  There are lots of reasons for this (attorney fee schedules come immediately to mind) that have nothing to do with formularies.  But adopting a formulary in a state with injured worker representation in the single digits is a fundamentally different proposition than adopting it in a state where 4 out of every 10 injured workers on indemnity have a lawyer.

Finally, loss adjustment expense in CA is already running at about 35% of total losses (which is 83% higher than the median in WCRI's latest study on LAE).  When the TX formulary came into full effect in 2013, the number of IRO decisions from 2013-2015 ranged in the 1200-1400 range per year over that three year period post-formulary implementation.  The number of IMR decisions in CA in 2016?  164,136.  And this is before the adoption of a formulary. Long term, as the prescriber community adjusts to the formulary list and its associated rules, the number of medication-related IMRs may in fact moderate.  But for the latter half of 2017, I wouldn't count on that happening.

Two different states, two different formularies, two different environments.  Beware of drawing conclusions regarding one based on the other.

Michael
On Twitter @PRIUM1

Monday, February 27, 2017

What if We Hypothesized Instead of Diagnosed?

The 19th century Romantic poet John Keats was also trained as a physician.  And it's his definition of a "man of achievement" that gives Arabella Simpkin and Richard Schwartzstein their jumping off point in a fascinating essay in the New England Journal of Medicine.  Wrote Keats regarding the necessary quality of such a person: "...when a man is capable of being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason."

How many physicians do you know who would agree with that sentiment?

Simpkin and Schwartzstein go on to make a noble and necessary argument for the place of uncertainty in modern medical practice.  While the proposal is made for the entirety of the profession and the full span of specialties, I was struck by the applicability of the argument to chronic pain management, specifically.
Too often, we focus on transforming a patient’s gray-scale narrative into a black-and-white diagnosis that can be neatly categorized and labeled. The unintended consequence — an obsession with finding the right answer, at the risk of oversimplifying the richly iterative and evolutionary nature of clinical reasoning — is the very antithesis of humanistic, individualized patient-centered care.
This is how non-specific low back pain turns into a 15 year old work comp claim.

The authors make several recommendations, each of which targets the very heart of medical education and clinical practice culture.  We need to cease viewing uncertainty as a threat, but rather embrace it as part of the iterative nature of care.  We need to move away from multiple choice tests in medical education that require definitive answers and instead focus on evaluating medical students' tolerance for uncertainty and ability to posit based on incomplete information.

Perhaps the most daunting recommendation they make, though, is the idea of moving away from concept of diagnosis and instead focusing doctor-patient conversations on the concept of hypothesis.
We can speak about “hypotheses” rather than “diagnoses,” thereby changing the expectations of both patients and physicians and facilitating a shift in culture. This shift may entail discussing uncertainty directly with patients, intentionally reflecting on its origins — subjectivity in the illness narrative, diagnostic sensitivity and specificity, unpredictability of treatment outcomes, and our own hidden assumptions and unconscious biases, to name a few. We can then teach physicians specifically how to communicate scientific uncertainty, which is essential if patients are to truly share in decision making, and we can reduce everyone’s discomfort by reframing uncertainty as a surmountable challenge rather than as a threat.
This requires treating the whole patient.  This requires recognizing the psychological and social contributors to pain perception and tolerance.  This requires seeing through the psychotropic effects of opioids and other addictive medications to get to the root cause issues of chronic pain.  This requires not just patient advocacy, but truly shared decision making.

Of course, this would also require us to move away from the dilapidated and counter-productive world of fee-for-service billing.  This would also require payers and employers to pay for quality, a genuine willingness to pay more dollars for less care (in the traditional sense) and more shared decision making (which will inevitably lead to better outcomes).

So there's a little slice of utopia for you, this Monday morning... with a heaping side helping of reality.

Michael
On Twitter @PRIUM1

Monday, February 20, 2017

Narrative Does Matter: Self-Guided Opioid Weaning

Perhaps it's obvious.  I write blog posts with regularity, I consume news voraciously, and I've never met a microphone I didn't enjoy speaking into.  But in the event it's not readily apparent, I'm happy to share that the single most important concept in contemporary communications is this: narrative.

"Narrative" is occasionally used as an epithet in political discourse (as in "you're just choosing facts that fit your narrative") and I'm as concerned as anyone else about the balkanization of modern media (which I describe as "choose your own narrative"), but the power of well-told stories to shape, change, or at least influence thinking is undeniable.  We live in a world of competing narratives and while the ability to identify such is critical, the ability to create such can be transformative.

Health Affairs understands this.  Whenever I get a new issue, I typically flip directly to my favorite section: "Narrative Matters."  Here, public health workers on the front lines share stories of what it means when platitudes turn into policy.  It's one thing to talk in the abstract about the CDC's Ebola response... it's quite another to listen to a doctor tell the story of running an Ebola clinic in Liberia.

This month's issue contains another in a long line of compelling stories, though this one hits close to home for those of us fighting to stem the tide of prescription drug misuse and abuse.  The story comes to us from Travis Rieder, a research scholar at the Johns Hopkins Berman Institute of Bioethics.  His journey, despite his role at Hopkins, doesn't have anything to do with his role in public health.  Travis likes to ride motorcycles... and his story begins with a horrific motorcycle accident.

I won't retell the story (you really should read it for yourself), but to summarize: Travis ended up deeply dependent on opioid painkillers.  Knowing he needed to stop taking them, he initiated his own weaning protocol (that was, in retrospect, far too aggressive - even thought it was suggested by one of his doctors).  He lived in agony for days, then weeks.  But he stuck to his plan.  At one point, it got so bad, he contemplated suicide.

Where were his doctors, you ask?  He found the medical profession to be some combination of afraid, inept, reluctant... perhaps all of the above... to assist in the weaning of his opioids.  And this was a motivated patient, asking to be weaned.  A highly educated, white collar academic who was begging for help... and got none.  "How could it be that my doctor's best tapering advice led to that experience?" Travis asks, "And how could it be that not one of my more than ten doctors could help?"  And think: this story found its way to Health Affairs because Travis is a known author in the field of bioethics.  How many non-bioethicists out there are suffering in this same opioid purgatory?

As my colleague Mark Pew has written about extensively, we've arrived at the hard work cleaning up the mess.  He even created a hashtag for it (#cleanupthemess), not because we're trying to score marketing points, but because we needed an organizing principle for the combined and coordinated effort its going to take to accomplish our collective goal.

Travis's story highlights the fact that the clean up may be harder than we imagine.

Michael
On Twitter @PRIUM1


Monday, February 13, 2017

We're Skipping the Simple Steps in Chronic Pain Management

"Take deep breaths.  Drink lots of water.  Get some extra sleep."

This is the prescription I tend to apply, at least initially, to all complaints of illness emanating from my three children.  I find it's effective approximately 90% of the time.  For the 10% of the time it's not effective, we escalate to mom... and occasionally from there, we head to the doctor.  Nothing special here, just basic triage for childhood illness.  

The problem I see is that adults often skip a step or two (or three) in this process.  And there's a lot of scientific data to support the reliance on these initial steps in the management of chronic pain.

Take Deep Breaths
There's ample evidence to suggest that relaxation techniques and mindfulness exercises can significantly influence chronic pain management.  This study, among dozens of high quality studies available (and hundreds more of lower quality), showed a >50% decrease in Total Pain Rating Index for 50% of the patients involved in the study.  Granted, small sample... but really compelling results.  Why did I pick this study to highlight?  It was published in April 1982.  This isn't new, folks.
An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results.

Drink Lots of Water
The link between dehydration and chronic pain is a little more recent, but still compelling.  A recent study from the journal Psychophysiology linked hypohydration (not as severe as dehydration, but still not healthy... essentially, most of us are walking around hypohydrated) with lower pain sensitivity thresholds.  We also know that the discs in the lower back require proper hydration for optimal functionality.  Getting enough water also effects are immune system response.  We've been told since we were kids to drink lots of water, it's just that none of us actually do that.
A preliminary study on how hypohydration affects pain perception

Get Some Sleep
Sleep hygiene is among the most overlooked elements of chronic pain management.  This topic is admittedly made complicated by the 'chicken and egg' nature of problem - to manage chronic pain, one needs to get more sleep, but sleep is often inhibited by chronic pain symptoms.  This nasty cycle is often addressed by sleep aid medications which are not indicated for long term use (and, as we well know, that doesn't stop them from being used long term).  One way off of this hamster wheel is ensuring that relaxation and hydration are incorporated into daily habits.  Along with mindfulness techniques, one must also incorporate a simple set of sleep management tips that are hard for people to come to grips with: going to bed and waking up at the same time every day, no television or other electronic devices in the bedroom, no alcohol or caffeine assumption.  How many Americans, in chronic pain or not, can pull of that bedtime routine?
Pain & Sleep: Information from the National Sleep Foundation

No, not all chronic pain can be managed by taking deep breaths, drinking lots of water, and getting plenty of sleep.  Some chronic pain has to be escalated to the care of medical professionals and these patients deserve the best, evidence-based care available.  But far too often, chronic pain is diagnosed and immediately treated with surgery and/or medications without an attempt at patient self-regulation based on simple principles of mindfulness, proper diet, and good sleep hygiene - all three of which, when missing, significantly contribute, even exacerbate, chronic pain.

Take deep breaths.  Drinks lots of water.  Get some sleep.

Michael
On Twitter @PRIUM1

Monday, January 30, 2017

Chronic Pain: Do We Even Know What We Don't Know?

My wife is currently training to become a yoga instructor.  Our conversations have begun to revolve around concepts like "being present" and "finding my center."  I'm a somewhat reluctant participant in such conversations and even though I understand all of the individual words being used, I admit the concepts are largely lost on me.  One thing that has resonated with me, though, is the humility that one can derive by recognizing what one does not know.  We can start to develop more rational and realistic responses to life's problems when we step back and question the basis of our views.

Two studies caught my attention recently and reminded me of this important principle.  In the swirl of debate and conjecture surrounding contemporary approaches to pain management, I think it's critical for us to distinguish what we know and what we don't know.

First, from the joint efforts of radiology service provider Spreemo and the Hospital for Special Surgery (HSS), we learned that objective diagnoses for low back pain aren't as straightforward as one might think.  A single patient was sent to 10 different centers to get an MRI of the lower back.  Of the 49 distinct objective findings identified across the 10 centers, not a single finding was identified by all 10 centers.  The study points to a potential diagnostic error rate of up to 43%.  

Next, from the Proceedings of the National Academy of Sciences, we learned that opioids might actually prolong neuropathic pain.  The paper titled "Morphine paradoxically prolongs neuropathic pain in rats by amplifying spinal NLRP3 inflammasome activation" is a technical piece, to say the least and I won't claim to have comprehended all of it.  But here's a snippet from the conclusion of the paper that I did understand (mostly):

In summary, the mechanisms underlying the transition from acute to chronic pain are poorly understood. We discovered that a short course of morphine administered upon expression of neuropathic pain remarkably doubled the duration of CCI-allodynia. This process was dependent upon dorsal spinal microglial reactivity and NLRP3 inflammasomes. These findings comport with prior demonstrations that repeated immune challenges induce a transition from acute to chronic pain, which may also underpin pain comorbidities. An evaluation of the long-term consequences of opioid treatment for chronic pain will identify whether this phenomenon manifests clinically.

It's really astounding to think about how much we don't know when it comes to chronic pain.  For all the time we spend debating the use of opioids for the treatment of low back pain, it's both frightening and illuminating to realize we get the diagnosis wrong almost 50% of the time and the drugs we use to treat it might actually make it worse.  

Long way to go...

Michael
On Twitter @PRIUM1

Monday, January 16, 2017

The Mistakes That States Make

As 2017 gets rolling, state legislatures are convening all over the country.  Several of them are about to make mistakes in the area of medication management in workers' compensation.  

My colleague, Mark Pew, and I have written and spoken extensively on the topic of drug formularies. And we're currently working, formally and informally, with regulators and other stakeholders in jurisdictions across the country on approaches that make sense for employers, doctors, pharmacists, and, most importantly, injured workers.  While there's not a lot to be gained for any of us in calling out individual states, there's a great deal at stake for all of us in the successes and failures of drug formulary implementations.  A failure (perceived or real) in one jurisdiction can lead another jurisdiction to delay its own attempt at a formulary - or to scrap it altogether.

So how can we tell if a law or rule set is headed in the right direction?  Or, alternatively, if a state's efforts are more likely to lead to sub-optimal results?  Here's a quick litmus test that you can apply to make your own determination:

1) Will the formulary rely on independent, 3rd party medical treatment guidelines?  
There's a great deal of industry discussion surrounding this topic, mostly focused on the definition of 'evidence-based medicine.'  While that conversation is interesting, it's not the critical factor in overall formulary success.  The crucial questions are two-fold: First, will there be room for political influence in the formation of the guidelines? Second, will the guidelines be updated with sufficient frequency?  

2) Does the formulary process build off of existing dispute resolution processes?
States that have successfully implemented drug formularies thus far have done so by relying on existing rules regarding resolution of medical treatment disputes.  States that try to simultaneously create a formulary and new dispute resolution processes to support it are, in reality, trying to do two things at once.  Not impossible, but certainly creates execution risk. 

3) Does the formulary allow for a remediation period for legacy claims?
On the one hand, a single effective date creates chaos as employers and physicians try to figure out how to address legacy claims, which tend to be more complicated. On the other hand, only applying new rules to new injuries creates two standards of care within a workers’ compensation system, where an injured worker’s treatment plan is driven entirely by the date on which they were injured (which makes no clinical sense). I look for regulatory language that takes a balanced approach – an initial implementation date for new injuries, followed by a remediation period for legacy claims, followed by a fully effective date for new rules and all claims. 

4) Is the formulary process scalable?  
I always look to see if the dispute resolution process can stand up to a significant volume of cases. While the goal of any formulary adoption should be to streamline access to medically necessary medications for injured workers, states should take a 'hope for the best, plan for the worst' approach.  Dispute resolution processes that rely on one individual or one office for ultimate resolution may lead to bottlenecks and, in a worst case scenario, undue influence.  I always ask myself - what will this look like if there are more disputes than the state expects?  

One bad apple can spoil the bunch.  Let's get this right.

Michael
On Twitter @PRIUM1  

Tuesday, January 10, 2017

Pain Acceptance: A Path Forward?

The world apparently needs more opioids, so the FDA approved another one yesterday.  Egalet Corporation's long-acting morphine formulation, Arymo ER, will hit the market here in the US before the close of Q1.  Interesting side note for those interested in the economic value of abuse-deterrence: Egalet stock initially shot up 27% on the approval news.  But when it became clear the Arymo label would only include abuse-deterrence language for dissolution and injection, but not for snorting or chewing it (because another abuse-deterrent opioid has rights to exclusivity for the particular claim), the stock dropped 16% yesterday and another 20% this morning.  By my calculations, that drop erased about $70 million in equity value.  And according to Yahoo Finance, 58% of the share are held by "insiders" (aka company executives) and one officer, Egalet CEO Robert Radie, holds nearly 50% of those insider shares.  So he's $20 million poorer this morning because he can't claim his new drug cannot be snorted or chewed.  If the mix of healthcare and high finance is a little nauseating to you, you're not alone.

In other pain management news, there's a really interesting study in this month's Journal of Pain Research regarding the relationship between "pain acceptance" and outcomes measures such as disability, mental health, and quality of life.  The study also relates this concept of "pain acceptance" to behaviors such as "pain catastrophizing," a phenomenon wherein a person "experiences exaggerated worrying and overestimation of the probability of unpleasant outcomes in response to pain." Notably, the study looks exclusively at a workers' compensation population.

Not surprisingly, higher "pain acceptance" scores were strongly correlated with less disability and greater mental and physical health.  "Pain catastrophizing" appeared to have the opposite effect - increased disability and poorer perceived health.  If you're wondering why you're hearing so much these days about cognitive behavioral therapy, this is why.

The study caused me to contemplate the broader picture of where we stand on the issues of chronic pain and opioid use.  We get lost in the statistics sometimes and fail to see the forest for the trees. Here's the real bottom line: the last quarter century has seen both an explosion in chronic pain and an explosion in opioid use.  The latter does not appear to be mitigating the former.  At all.

From another (highly clinical/technical) study that also crossed my desk last week from the Department of Palliative Care at Geisinger Medical Center, I drew this important insight: "Do not use pain intensity as the primary outcome in the management of chronic pain."  Sounds pretty simple.  But do we use, then?  Perhaps a greater focus on concepts like "pain acceptance" will help us break through the chronic pain conundrum.

Michael
On Twitter @PRIUM1


Monday, December 19, 2016

The Tobacco Playbook: Opioids Go Global

Remember when the full weight of federal and state governments, along with support from advocacy and public health groups, finally came crashing down on the heads of the tobacco industry?  Do you remember what the tobacco industry did?  They went global.  Today, 75% of the world's smokers live in developing countries. The growth of tobacco use in the developing world hinges on the lack of regulatory controls at each critical step in the value chain: manufacturing, distribution, marketing, retail sales, consumption - it's just easier to get people hooked in the developing world.

A refresher on an oft-quoted statistic: the US is less than 5% of the world's population, but we consume 80% of the world's opioid supply.  As regulatory scrutiny grows around opioid manufacturers, we might expect them to behave as the tobacco industry has over the last quarter century or more.  Imagine if, at some future date, 80% of opioids were consumed outside the US. Would you have the moral courage to resist that investment temptation?

From the great work of the LA Times, we know that's exactly the plan our old friends at Purdue Pharma (makers of Oxycontin) are carrying out.  Through an international subsidiary (with a different name, of course), Purdue is pursuing overseas markets with much the same strategy as they did the US market in the late 1990s (and we can count on a similar result: foul deeds will rise).  They pay medical "experts" to give seminars to doctors that suggest opioids should be used more for pain management, not less.  In one instance cited in the article, Purdue was paying Dr. Joseph Pergolizzi to give such seminars.  Dr. Pergolizzi appears to have some credentialing issues, though.  He claimed an affiliation with Temple University as well as my own alma mater, Georgetown University.  When challenged on those affiliations, he claimed he was having "paperwork issues" at Temple and was "in discussions" with Georgetown.  I was heartened by my alma mater's response: "We are not in discussions with that gentleman."  Good stuff.

Two key questions over the next decade:
1) Will the public health infrastructure in the US, having learned from its experience with Big Tobacco, get out ahead of this potential international opioid crisis and warn developing countries about the dangers they face?
2) Will those developing countries listen?

Michael
On Twitter @PRIUM1

PS: As this will be the last post of 2016 for Evidence Based, I thought I'd take a moment to let you in on a little secret.  This past year was the 400th anniversary of the death of William Shakespeare (that's not a secret... hang with me a second...)  I have a great love of Shakespeare that was instilled in me by the greatest AP Lit teacher on planet Earth, Ross Friedman. He's retired now, but his love of language, culture, art, and great writing lives on in the thousands of students he taught through his career.

And that brings me to the secret of the Evidence Based blog in 2016: To honor The Great Bard (and my great teacher, Mr. Friedman), I have included an allusion to one of Shakespeare's plays or sonnets in every blog post I wrote in 2016 (above: "foul deeds will rise"is from Hamlet, Act I, Scene 2).  If you noticed, well then bonus points for you.  I had fun doing it and learned along the way that Shakespeare had something to say about everything... even healthcare, regulatory policy, and pharma companies.

Happy Holidays!  And thanks for reading!

Monday, December 12, 2016

Surveys Says? We Still Have a Long Way To Go On Opioids

Last week, I referred all of you to a piece by Dr. Stephen Martin wherein he offers a critique of the CDC opioid guidelines as well as the overall public health approach to opioid misuse and abuse. While I disagreed with most of his views, I thought the article represented the kind of informed dialogue in which we need to engage in order to move the public policy discussion forward (and I further suggested that our collective ability to engage in rational, data-driven debate will make us or mar us as a society). In the article, Dr. Martin sites a range of studies that put the risk of addiction to opioids somewhere between 2% and 10%.  He also suggests that the CDC's lack of focus on diversion - wherein lawful prescription drugs end up being 'diverted' from their intended purpose and routed into illegal drug trafficking - is a major issue.  He writes: "...the threat of addiction largely comes from diverted prescription opioids, not from long-term use with a skilled prescriber in a longitudinal clinical relationship."

Both those positions appear to be refuted by survey data collected by the Washington Post and Kaiser Family Foundation and published in the Post on Friday.

The Post and KFF surveyed 622 long term opioid users (defined as use for 2 months or longer) and 187 household members of long term opioid users.  The survey was taken over a roughly 5 week period from October 3 through November 9 and the overall results have a margin of sampling error of +/- 4 points.

We learn, among many other interesting things, that...

  • 34% of long-term opioid users say they are/were addicted or dependent on opioids
  • 54% of household members say the opioid user is/was addicted or dependent
  • Nearly all long-term users (95 percent) said that they began taking the drugs to relieve pain from surgery, an injury or a chronic condition. 
  • Just 3 percent said that they started as recreational users.
Further, the presumption of safety within a "longitudinal clinical relationship" is called into question by the fact that while the survey suggests a largely positive relationship between patients and doctors, only 33% of patients reported that their doctors discussed a plan for getting off of the medication at the onset of therapy.  That's a standard best practice... and two-thirds of doctors aren't doing it.  

Despite all of this data, the vast majority of survey respondents say these drugs have dramatically changed their lives for the better.  While their household members appear to have a different view, this highlights the difficult public health position in which we find ourselves. Benefits and risks aren't as clear cut as we wish they could be.  

Finally, I'm struck by staying power of the "100 million Americans in chronic pain" statistic.  The Post uses it here and it remains a pervasive data point for the justification of long term opioid use. But to steal a phrase from Dr. Martin himself (who stole it from Mencken), this statistic is "neat, plausible, and wrong." If we're going to have a debate about chronic pain, we have to start with the facts.  

Michael 
On Twitter @PRIUM1