1/This student of @SMeghani_PhD reports: medical practices want to stop opioids on all patients, or transfer the patients out, but cannot find any other practice to take them. The travesty is both unsafe and remediable https://twitter.com/smeghani_phd/status/1296156890548690945

2/The regulatory incentive in play is one that maximizes clinicians’ (and their employers’ and payers’) perception of liability: criminal, regulatory, and bureaucratic, in terms of the amount of uncompensated labor required to continue an #opioid prescription

3/The hope was that Rx reduction would address either causes of addiction or risk of harm. Clearly OD’s haven’t fallen. There’s room to argue that 2019 NSDUH shows hints of in heroin use among 18-25 yr-olds (0.8%0.5%) but cocaine rose. Table 7.11B https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHDetailedTabs2018R2/NSDUHDetTabsSect7pe2018.htm

4/But stacking of regulatory & legal liabilities on the care of patients with severe pain (by governmental & nongovernmental players) has caused effective abandonment and patient harm (regardless of views on whether patients were “well-served” by their opioid Rx or not).

5/My view: no health care payer, or regulator, should idly accept ongoing harm to patients. To not “stand idle” means to shift paradigms for what they are trying to accomplish at this point. The fig leaf of a in “high dose” or “total Rx” is NOT targeting what really matters

6/Clinicians and pharmacists need a bureaucratic & legal “safe harbor” in which initiation or continuation of #opioid Rx is not subject to the mercy of adverse metrics from @NCQA or criminal referral by @HHSGov OIG, which is what _they say they do_ https://oig.hhs.gov/oei/reports/oei-02-18-00224.asp

7/But that doesn’t get to the heart of it. Let’s call this “care for people with serious illness, often with pain, sometimes cancer, often co-existing mental health & social adversity”, almost always with stigma! Who does the work? Who is paid to do it? Don’t ignore that!

8/Rx #opioid reduction has played out like lighting a fuse & being surprised to find gunpowder at the end of it. In the , we have few options to offer multidisciplinary coordinated care, almost no quality standards,no training, & few patients have access to it.

9/This requires conceptualizing the care of severe long term pain as a *care obligation*, NOT an Rx control problem. We should pay for it, and we should call on insurers & quality metric agencies to *speedily* correct incentives for abandonment that they put in play @NCQA

10/a qualifier: This thread has NOT been on the clinical judgments about “taper” by experts with care- for people who want to pause and think about the clinical systems for that, I suggest this piece shared by @annafoat . https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0236419

11/since that piece reflects authors, I must note that regulation & guidance for medical practice in may set up for more serious problems of abandonment, because of the proliferation of regulators & centrality of a criminal justice agency in regulation of Rx’s ( @maiasz )

12/The message of this thread is to broaden focus and ask about the system we create in which patient abandonment is the logical step. I want us to pause and ask the institutions that guide our health care to _stop making it worse_. /FIN