The prescription opioid epidemic in a nutshell

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You are obviously much more skilled at scientifically and not arbitrarily deciding who needs or deserves "low dose" COT and then defending your decision when they croak from misuse or report you to the board of medicine for discriminating against them and not prescribing. I would be more comfortable dealing with the crap if I was saving a life. My bad for not being that skilled a pain doctor.


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A Closer Look
Examining the news
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Stephen Engelberg

In 2013, ProPublica released Prescriber Checkup, a database that detailed the prescribing habits of hundreds of thousands of doctors across the country.

ProPublica reporters used the data — which reflected prescriptions covered by Medicare’s massive drug program, known as part D — to uncover several important findings. The data showed doctors often prescribed narcotic painkillers and antipsychotic drugs in quantities that could be dangerous for their patients, many of whom were elderly. The reporters also found evidence that some doctors wrote far, far more prescriptions than their peers for expensive brand-name drugs for which there were cheaper generic alternatives. And we found instances of probable fraud that had gone undetected by the government.



The data proved equally useful for others: Doctors themselves turned to Prescriber Checkup to assess how they compared to their peers. Medical plan administrators and hospitals checked it to see whether their doctors were following best practices in treating patients. Law enforcement officials searched the database for leads on fraud and illicit trafficking in pain medications. Patients turned to the data to vet their doctors’ drug choices and compare them with others in their specialties.

Recently, though, we picked up clear signs that some readers are using the data for another purpose: To search for doctors likely to prescribe them some widely abused drugs, many of them opioids.

Like nearly everyone on the web, we use Google Analytics to collect data on our site. So far this year, it appears that perhaps as many as 25 percent of Prescriber Checkup’s page views involve narcotic painkillers, anti-anxiety medications, and amphetamines.

Thousands of the people visiting those pages initially viewed the “reporting recipe” we wrote to help local journalists identify doctors who ranked among the top prescribers of narcotics. The readership for this recipe far exceeds any reasonable estimate of local or regional journalists researching stories. According to our web data, many readers also arrived at Prescriber Checkup after web searches like “doctors who prescribe narcotics easily’’ or “doctors that will prescribe anything.’’

It’s not possible to draw definitive conclusions about the motives of these people. Some, no doubt, legitimately have chronic pain or anxiety and are simply looking for doctors who will help them. Two of the more frequently searched drugs are Suboxone and methadone, medicines used to treat opioid addiction. (As the depth of the opiod epidemic has become clear, some doctors have become reluctant to prescribe these drugs out of fears that they, too, can be abused.) Still, it seems probable that some of the readers who visit Prescriber Checkup are looking for doctors who will prescribe narcotics and other powerful stimulants with few or no questions asked.

This is not a new problem for journalists, or others whose business is providing or sharing information. In another era, burglars would read the obituary pages so they could target the homes of people who had just died. More recently, terrorists have used search engines to find recipes for bomb-making or encrypted communications. Con artists have found new ways to perpetrate schemes through Facebook and other social media.

The Internet’s leading platforms have struggled with this issue. Just this week, Google announced that it would not accept ads for payday lenders. Both Facebook and Google bar advertising for guns, explosives and recreational drugs.

We impose comparable limits on the advertising we are willing to accept on our site. But as a news organization dedicated to pursuing stories with “moral force,’’ we feel we also have an obligation to look hard at possible misuses of our journalism.

We have long been advocates for transparency and have repeatedly pushed government agencies to release more data on everything from dialysis clinics to complications in surgical procedures performed under Medicare. In almost every one of these instances, some government officials argued against making the information public, warning that the information would be misused.

Initially, when we published Prescriber Checkup, we had to request the data under the Freedom of Information Act. The government has come around to see the value of releasing prescribing information. Now, the Centers for Medicare and Medicaid Services puts the data freely on its own site. It even has a tool that allows people to compare doctors based on their opioid prescribing, just as our site does.

Prescriber Checkup
The doctors and drugs in Medicare Part D. Explore the data.

Using Prescriber Checkup: A Quick Guide
We've made it easy to search for doctors and other health providers who are active in Medicare's drug program. See our tips.

We continue to believe that Prescriber Checkup provides significant and beneficial insights into prescribing patterns — insights that can help patients, practitioners, regulators and a variety of other users. Doctors, the vast majority of whom want to do the right thing, have told us that this is the only place where they can measure their prescribing against colleagues in their specialty and state. And we regularly hear from law enforcement and medical board regulators across the country who say our tool helped them focus their efforts in ways that previously were not available.

Still, we recognize that it’s important not to ignore the not-so-beneficial uses of Prescriber Checkup. As one way of doing this, we are adding a warning to the pages of all narcotic drugs that reminds readers of the serious health risks posed by taking opioids for pain relief. We will also link to advice on their use by the Centers for Disease Control and Prevention and have written a story on the growing public health crisis arising from the abuse prescription pain medication. We will continue to report on this issue, as we’ve done previously.

Data journalism gives readers access to a stunning array of information on everything from healthcare to election results. As data sets grow ever larger, they also introduce ethical questions that journalists will be weighing for many years to come. We hope the actions we’ve taken contribute to that conversation


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A staffer with the attorney general’s office told the board Cozzi started out seeing 70 patients a day and now sees between 80 and more than 100 a day. One patient told the attorney general’s office that Cozzi’s office was “the land of Mountain Dew, nicotine and despair.”

The staffer said Cozzi was responsible for 200 medicaid overdoses.

The board learned that the Tuesday raids of Cozzi’s home turned up “obscene amounts” of ammunition and more than 50 guns, including AR-15s in the garage. Agents reportedly found kitchen drawers stuffed with cash, cash wrapped up in aluminium foil balls in bathroom drawers. Patient files and drugs were also found.
 
A staffer with the attorney general’s office told the board Cozzi started out seeing 70 patients a day and now sees between 80 and more than 100 a day. One patient told the attorney general’s office that Cozzi’s office was “the land of Mountain Dew, nicotine and despair.”

The staffer said Cozzi was responsible for 200 medicaid overdoses.

The board learned that the Tuesday raids of Cozzi’s home turned up “obscene amounts” of ammunition and more than 50 guns, including AR-15s in the garage. Agents reportedly found kitchen drawers stuffed with cash, cash wrapped up in aluminium foil balls in bathroom drawers. Patient files and drugs were also found.
So how the hell was it dismissed? He paid off the judge, attorneys etc.?
 
Pick another profession. Some patients will need low dose COT. Not prescribed by their PCP, but that's PART of our role as pain docs.

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Agree with you that some patients do need low dose COT. What is everyone's cutoff for "low dose" ?
 
So how the hell was it dismissed? He paid off the judge, attorneys etc.?

Many of these guys have accumulated enough money that they hire multiple lawyers that are really really good. Yea, we may hear about the raid, we hear about license suspensions, etc, but we don't hear about the aftermath, including getting reinstated back to practicing their specialty with restrictions.
In this case, I'm kind of shocked too. Wtf.
 
If u read that article and others, he was initially arrested for felony possession of cocaine or narcotics. THOSE specific charges were allowed to expire. His license has already been suspended.

He is fighting to get his armamentarium back... Apparently he has over 50 guns.

With the current climate, I'm sure he will get them back. He won't be able to legally prescribe, but with his guns...........


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http://jama.jamanetwork.com/article.aspx?articleID=2528212
June 14, 2016, Vol 315, No. 22 >

< Previous Article
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Original Investigation | June 14, 2016
Prescription of Long-Acting Opioids and Mortality in Patients With Chronic Noncancer Pain
Wayne A. Ray, PhD1; Cecilia P. Chung, MD, MPH2; Katherine T. Murray, MD2,3; Kathi Hall, BS1; C. Michael Stein, MB, ChB2,3
[-] Author Affiliations
1Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
2Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
3Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
JAMA. 2016;315(22):2415-2423. doi:10.1001/jama.2016.7789.


ABSTRACT | INTRODUCTION | METHODS | RESULTS | DISCUSSION | CONCLUSIONS |ARTICLE INFORMATION | REFERENCES
Importance Long-acting opioids increase the risk of unintentional overdose deaths but also may increase mortality from cardiorespiratory and other causes.

Objective To compare all-cause mortality for patients with chronic noncancer pain who were prescribed either long-acting opioids or alternative medications for moderate to severe chronic pain.

Design, Setting, and Participants Retrospective cohort study between 1999 and 2012 of Tennessee Medicaid patients with chronic noncancer pain and no evidence of palliative or end-of-life care.

Exposures Propensity score–matched new episodes of prescribed therapy for long-acting opioids or either analgesic anticonvulsants or low-dose cyclic antidepressants (control medications).

Main Outcomes and Measures Total and cause-specific mortality as determined from death certificates. Adjusted hazard ratios (HRs) and risk differences (difference in incidence of death) were calculated for long-acting opioid therapy vs control medication.

Results There were 22 912 new episodes of prescribed therapy for both long-acting opioids and control medications (mean [SD] age, 48 [11] years; 60% women). The long-acting opioid group was followed up for a mean 176 days and had 185 deaths and the control treatment group was followed up for a mean 128 days and had 87 deaths. The HR for total mortality was 1.64 (95% CI, 1.26-2.12) with a risk difference of 68.5 excess deaths (95% CI, 28.2-120.7) per 10 000 person-years. Increased risk was due to out-of-hospital deaths (154 long-acting opioid, 60 control deaths; HR, 1.90; 95% CI, 1.40-2.58; risk difference, 67.1; 95% CI, 30.1-117.3) excess deaths per 10 000 person-years. For out-of-hospital deaths other than unintentional overdose (120 long-acting opioid, 53 control deaths), the HR was 1.72 (95% CI, 1.24-2.39) with a risk difference of 47.4 excess deaths (95% CI, 15.7-91.4) per 10 000 person-years. The HR for cardiovascular deaths (79 long-acting opioid, 36 control deaths) was 1.65 (95% CI, 1.10-2.46) with a risk difference of 28.9 excess deaths (95% CI, 4.6-65.3) per 10 000 person-years. The HR during the first 30 days of therapy (53 long-acting opioid, 13 control deaths) was 4.16 (95% CI, 2.27-7.63) with a risk difference of 200 excess deaths (95% CI, 80-420) per 10 000 person-years.

Conclusions and Relevance Prescription of long-acting opioids for chronic noncancer pain, compared with anticonvulsants or cyclic antidepressants, was associated with a significantly increased risk of all-cause mortality, including deaths from causes other than overdose, with a modest absolute risk difference. These findings should be considered when evaluating harms and benefits of treatment.
 
First!!


Oh wait, wait. That means I can say...

GIGA!!!!


Or was that GIGO....


(FYI this post was supposed to be in magenta but I forgot how... /color?)


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First!!


Oh wait, wait. That means I can say...

GIGA!!!!


Or was that GIGO....


(FYI this post was supposed to be in magenta but I forgot how... /color?)


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Yes, all studies are garbage:) But especially those by Roger Chou!
 
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The study involved only Medicaid patients, who include low-income and disabled adults and who are among groups disproportionately affected by opioid abuse

Ray noted that the study excluded the sickest patients and those with any evidence of drug abuse. He said similar results would likely be found in other groups.


So All medicaid and excluded those with substance abuse. ??? Joking, right?
 


on right now, on CNBC, on the Florida pill mills.

dont know when the episode will be available online. hopefully soon. worth watching.
 
Purdue & JCAHO...

http://www.fda.gov/ohrms/dockets/dailys/04/jan04/012804/04p-0043-cp00001-19-tab16-vol1.pdf

JCAHO Pain Management Initiative JCAHO (Joint Commission Agency that accredits hospitals) will continue to be the focus of a major initiative focusing on pain assessment and treatment. Purdue has taken a major leadership role in helping hospitals meet the JC&iO requirements, in this area through the development of pain assessment and pain management materials geared to the hospital setting. Purdue supported the educational efforts of the JCAHO in an exclusive agreement throughout 2001 by supporting two pain summits and seven regional educational symposia. Purdue also supported the development of a video series to educate providers, as weli as education for the JCAHO pain summits with unrestricted educational grants. Another significant opportunity presents itself in 2002 for Purdue to support the efforts of JCAHO. This initiative represents an opporttmit? to provide true value-added education on pain management and, at the same time, continue Purdue’s leadership in pain management. As a whole, the JCAHO initiative has provided the field force with many opportunities to conduct in-service presentations and to position OxyContin appropriately for pain.
 
the numbers in that document are staggering. $21.5 MILLION in marketing for 2002. $490,000 to JCAHO.

and supposedly it "is the doctors' fault" there is a prescription opioid epidemic, when the very organization that is supposed to enforce quality care gets an almost half million dollars a year...
 
so many misconceptions in this article.

i suppose im supposed to feel empathy for this individual. its hard to feel empathetic to a former cocaine addict who knows still where to get the "good" stuff

is the heroin helping him get his life back? the article states he is still in severe pain while on heroin.
is he back to work on heroin? if so, why is he now living out of his truck?

additionally, he shouldnt be going to a methadone clinic, he should be going to suboxone clinic.
 
Wait...wait a minute....hold the show. There are alternative treatments for chronic pain other than high dose opioids? When did this happen?
 
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I think it would be reasonable to limit scheduled to opiates to fellowship-trained pain Physicians. The public would cry about the Harm's done and the government would cry about the saved lives. Only we are in a position to determine who may benefit. We could eliminate 90% of patients on opiates overnight. Of course the argument could be that the suicide rate will increase due to patients not having access to this modality. I don't have a good answer on this other than opiates do not save lives.
 
However there are only about 2800 fellowship trained docs and i would wager some of them are no longer practicing pain medicine and at least 1/3 prescribe no opioids leaving around 1600 to prescribe for 320,000,000 people....a patient to doctor ratio of 200,000:1
 
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I think it would be reasonable to limit scheduled to opiates to fellowship-trained pain Physicians. The public would cry about the Harm's done and the government would cry about the saved lives. Only we are in a position to determine who may benefit. We could eliminate 90% of patients on opiates overnight. Of course the argument could be that the suicide rate will increase due to patients not having access to this modality. I don't have a good answer on this other than opiates do not save lives.
As a PCP, I would be 100% OK with something that limits what I can prescribe. We can even be on the generous side and do both a MED and an absolute pill limit - say no more than 20-30 MEDs/day and no more than say 90 pills of any kind/month. That'll weed out the 120 norco/percocet per month people while leaving us the arthritic 90 year olds who take BID norco in the morning and at bedtime who don't actually need a fellowship-trained pain doctor anyway.
 
However there are only about 2800 fellowship trained docs and i would wager some of them are no longer practicing pain medicine and at least 1/3 prescribe no opioids leaving around 1600 to prescribe for 320,000,000 people....a patient to doctor ratio of 200,000:1
I say we volunteer 101N to take 319,000,000...
 
As a PCP, I would be 100% OK with something that limits what I can prescribe. We can even be on the generous side and do both a MED and an absolute pill limit - say no more than 20-30 MEDs/day and no more than say 90 pills of any kind/month. That'll weed out the 120 norco/percocet per month people while leaving us the arthritic 90 year olds who take BID norco in the morning and at bedtime who don't actually need a fellowship-trained pain doctor anyway.
Your ideal management of the 90yo can be applied to all pain patients from the onset... Not sure why it takes the Feds to shake up the PCPs
 
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Your idea management of the 90yo can be applied to all pain patients from the onset... Not sure why it takes the Feds to shake up the PCPs
Because most PCPs have been practicing since before we knew how bad the opioid problem was. Me personally, if you need more than 1 of any narcotic every other day then you're going to pain management. Older docs aren't as strict (nor are younger ones who only care about a paycheck).
 
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Shouldn't you disclose your membership on the PROP board, 101N? Don't you think that colors your viewpoint?
 
And if your "watch list" is able to be manipulated for personal vendettas, you don't really think anyone will take it seriously, do you?

But by all means, keep trying to bully those of us who challenge you. Your threats and intimidation tactics confirm you are in this for personal gain, and that you lack credibility.
 
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And if your "watch list" is able to be manipulated for personal vendettas, you don't really think anyone will take it seriously, do you?

But by all means, keep trying to bully those of us who challenge you. Your threats and intimidation tactics confirm you are in this for personal gain, and that you lack credibility.

Double secret probation?
 
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just because he is a member of an organization for or against opioids does not bias him or affect his credibility. what biases him - or anyone - are ulterior financial gain with regards to his/her positions...

as far as I can tell, from propublica, he has not received financial gain from his involvement in PROP.

I would hold the opinion of opioid-supporting leaders in pain management who do not recieve financial renumeration, in equal regard to those who are members of PROP (who, as I can tell, don't get paid for their work)... but unfortunately, I cant find any.

I wonder why...

addendum: maybe Dr. Larry Driver of PROMPT...
 
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just because he is a member of an organization for or against opioids does not bias him or affect his credibility. what biases him - or anyone - are ulterior financial gain with regards to his/her positions...

as far as I can tell, from propublica, he has not received financial gain from his involvement in PROP.

I would hold the opinion of opioid-supporting leaders in pain management who do not recieve financial renumeration, in equal regard to those who are members of PROP (who, as I can tell, don't get paid for their work)... but unfortunately, I cant find any.

I wonder why...

addendum: maybe Dr. Larry Driver of PROMPT...

A potential financial conflict of interest is but only one kind of narrow conflict of interest. Most policymakers define the concept more broadly--a confluence of interests...

http://www.policymed.com/2015/09/confluence-not-conflict-of-interest-name-change-necessary-.html

Instead, there is nothing wrong with openly declaring your biases, owning your affiliations, and disclosing sources of indirect motivation and interests.
 
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Being a member of PROP's board of trustees (not just a member of the organization) brings with it prestige. Indirectly, it results in appointment to posts like the Oregon Pain Management Commission (https://www.oregon.gov/oha/OHPR/PMC/Pages/members.aspx) and to be asked to consult for the state medical board.

Those type of positions, in turn, lead to other lucrative gigs.

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I've had to delete a few posts containing the real names of users. Please don't refer to other users by their real names on the public forum, unless of course their username is their real name.

This is also a reminder that when discussing controversial issues in our specialty, keep the discussion to matters regarding the issues rather than accusations regarding individual users.
 
Being a member of PROP's board of trustees (not just a member of the organization) brings with it prestige. Indirectly, it results in appointment to posts like the Oregon Pain Management Commission (https://www.oregon.gov/oha/OHPR/PMC/Pages/members.aspx) and to be asked to consult for the state medical board.

Those type of positions, in turn, lead to other lucrative gigs.

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Very true drusso.

However, your point ampha is a little more tenuous.

One does not necessarily join an - initially - unpopular organization with the expectations of advancing ones career. That is not exactly self serving.

By your measure, any involvement in any public policy could bring prestige or infamy and essentially invalidates the opinions of that individual.

If that is what you desire, that go at it.

In the meantime, do your own review of the literature and find all the articles that support long term opioid therapy...


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I've had to delete a few posts containing the real names of users. Please don't refer to other users by their real names on the public forum, unless of course their username is their real name.

This is also a reminder that when discussing controversial issues in our specialty, keep the discussion to matters regarding the issues rather than accusations regarding individual users.
Your prior policy had a carve out if folks had no problem with their name being used. Perhaps 101N isn't willing to take public ownership of his views and positions. I (Peter Zimmerman) am.

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Very true drusso.

However, your point ampha is a little more tenuous.

One does not necessarily join an - initially - unpopular organization with the expectations of advancing ones career. That is not exactly self serving.

By your measure, any involvement in any public policy could bring prestige or infamy and essentially invalidates the opinions of that individual.

If that is what you desire, that go at it.

In the meantime, do your own review of the literature and find all the articles that support long term opioid therapy...


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He is not a member of PROP, he is on their Board of Trustees.

I am in no way advocating the use of high dose opioids. I am pointing out the the SDN Pain Board's most ardent critic of IPM is a hypocrite, as he performs these procedures himself. I am pointing out that the SDN Pain Board's most ardent supporter of PROP and their positions doesn't practice what he preaches. I do not have a single patient in my practice on doses that exceed the CDC guidelines. I would challenge 101N to make a similar claim.
 
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From the Terms of Service:

"Please keep your identity protected – don’t post or use your real name on the forums. Additionally, members are not permitted to solicit personally identifiable information from other members (such as through research surveys, etc.) without written permission from SDN or disclose another member’s identity without their written permission."

I had made an exception for the private forum, but on the public forum maintain anonymity and do not ask other users to share their identities publicly.
 
He is not a member of PROP, he is on their Board of Trustees.

I am in no way advocating the use of high dose opioids. I am pointing out the the SDN Pain Board's most ardent critic of IPM is a hypocrite, as he performs these procedures himself. I am pointing out that the SDN Pain Board's most ardent supporter of PROP and their positions doesn't practice what he preaches. I do not have a single patient in my practice on doses that exceed the CDC guidelines. I would challenge 101N to make a similar claim.

As I've said before, opioids PROP/PROMPT, and CS are all proxy wars for what really
angers you. I am not a believer in the IPM-physician being the shepherd of the CNP
flock we have failed with pills and procedures. Get used to hearing it.

That said, I realize that not all IPM can be painted with the same brush. Like a lot of things
in life professional ethics exists upon a continuum:)

http://www.rep-am.com/lifestyle/2016/09/11/training-in-pain-management-is-not-a-top-priority/

"Still, Becker, who researches pain management at Yale, does not believe more pain specialists will solve the problem. “Yes, there are not nearly enough ‘pain specialists,'” he said. “But really pain specialists are not suited to managing chronic pain. Historically, they have been more interested in highly reimbursed procedures that aren’t really what improve outcomes in patients with chronic pains.” He pointed to epidural steroid injections for the back, which, he said, have not been demonstrated as effective for long-term relief. “We need more generalists who are fluent in the treatment of chronic pain,” he said."
 
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