tag:blogger.com,1999:blog-134951252024-03-14T04:06:56.612-05:00PallimedPallimed covers current palliative medicine, hospice, and end-of-life research and news, with a particular focus on publications not from the major palliative care journals. It is aimed at health care professionals who work with people nearing the end of life.Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.comBlogger1739125tag:blogger.com,1999:blog-13495125.post-36753394654644237772022-11-29T09:00:00.004-06:002022-11-29T09:00:00.196-06:00Undisclosed Conflicts of Interest by Physicians Creating the CDC Opioid Prescribing Guidelines: An Epilogue<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgKI54muav9pWFpKov8zk_2GY42awvzEf1s003HLcyQI0jy3QmAaFCpp5qR9rnQoTSyjGWeIQ9ooisChtdyx0WiAjY9Rf4N1XePQ1hqqx7m49s9822fkU0DusfyepW9_U5T_Oz2cnuVnZ591WMozbfBoObckY2EhmNvt81Kng3KEr3h4V0DjIM/s1080/EAT.png" style="display: block; padding: 1em 0; text-align: center; clear: right; float: right;"><img alt="" border="0" width="320" data-original-height="1080" data-original-width="1080" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgKI54muav9pWFpKov8zk_2GY42awvzEf1s003HLcyQI0jy3QmAaFCpp5qR9rnQoTSyjGWeIQ9ooisChtdyx0WiAjY9Rf4N1XePQ1hqqx7m49s9822fkU0DusfyepW9_U5T_Oz2cnuVnZ591WMozbfBoObckY2EhmNvt81Kng3KEr3h4V0DjIM/s320/EAT.png"/></a></div>
by Chad D. Kollas, MD, Beverly Schechtman and Carrie Judy
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Several important developments have occurred since the publication of our article, “<a href="https://www.pallimed.org/2022/09/undisclosed-conflicts-of-interest-by.html" target="_blank">Undisclosed Conflicts of Interest by Physicians Creating the CDC Opioid Prescribing Guidelines: Bad Faith or Incompetence?” in Pallimed on September 12, 2022</a> (1). Most notably, this includes the publication of the 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain (2), which updated the guidance previously provided by the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain (3). In this epilogue, we will describe those important developments and examine how the 2022 revision of the Opioid Guideline (hereafter the 2022 Guideline) should affect pain care and national opioid policy in the future.
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<b>Disclosing Sullivan’s Conflicts of Interest</b>
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In our article, we criticized the medical journal, PAIN, and Mark Sullivan, a member of the advocacy group, Physicians for Responsible Opioid Prescribing (PROP), for failing to disclose his conflicts of interest related to his expert witness work in opioid litigation (1). Just two days later, on September 14, 2022, PAIN electronically published statements (4, 5) disclosing Sullivan’s previously omitted COIs. PAIN had initially acknowledged Sullivan’s COIs in May 2022 (6), but it is challenging to believe the timing of its disclosure and the publication of the Pallimed article was entirely coincidental.
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<b>CDC’s Response to FOIA Requests</b>
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We also noted in the Pallimed article that several other PROP members and allies who participated in the creation process of the 2016 Guideline had apparently failed to disclose other relevant conflicts of interest that may have been disqualifying under CDC rules and policies. We submitted a request to CDC under the Freedom of Information Act (FOIA) to provide materials that included their disclosures or a waiver from CDC from making the disclosure (7). On October 18, 2022, CDC provided disclosure agreements from Jane Ballantyne and Lewis Nelson that did not disclose their roles in developing and publishing opioid policy statements on behalf of PROP (8). Ballantyne disclosed her work in “legal consulting,” but did not clarify that this work involved receiving payments from law firms participating in multidistrict litigation against opioid manufacturers and distributors, which she had disclosed in several articles (1, 8, 9-12). It is unclear whether CDC investigated Ballantyne’s “legal consulting” disclosure more fully.
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Additionally, we sought clarification about Roger Chou’s conflicts of interest regarding his role as a co-author of both the 2016 and 2022 Guidelines via our FOIA request. The CDC’s reply was unusual in that it provided no responsive documents, but cited Chou’s public disclosure of his conflict of interest from the July 2021 Meeting of the CDC BSC-NCIPC and recusal from those proceedings (13). While following this response, we confirmed that Chou received funding in September 2014 from the Agency for Healthcare Research and Quality (AHRQ), through his role as the Director for the Pacific Northwest Evidence-based Practice Center and employment by Oregon Health and Science University (14). Based on CDC’s rules and policies for clinical guideline development, Chou should have disclosed that funding to CDC using the “Declaration of Interests for CDC Experts (1, 3).” In light of this, we placed another FOIA request seeking Chou’s “Declaration of Interests for CDC Experts” document for his 2014 AHRQ funding, but CDC forwarded that request to AHRQ on October 26, 2022 (15). On October 28, 2022, on behalf of AHRQ, a representative from Health and Human Services (HHS) responded “Your letter discusses issues outside of the scope of the FOIA, and does not appear to include a request for records, which is required in order to be treated as a FOIA request. Therefore, we have closed our file on this matter (16).” In the absence of any statement otherwise, we interpret this all to mean that CDC views Chou’s COI disclosure in July 2021 as applying to any authorship role in either iteration of the CDC Opioid Guideline.
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<b>The FSBM Workshop and an Unexpected Opportunity</b>
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The Federation of State Medical Boards held a workshop on opioids and addiction treatment on September 27 and 28, 2022, in Washington, DC, and one of us (CDK) provided testimony to that group as an invited guest (17). The workshop group included a representative from the CDC National Center for Injury Prevention and Control (NCIPC), which led to a series of meetings and communications with its leadership (18). These communications were very helpful in better understanding the 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain (2), which was released publicly on November 3, 2022, with an accompanying Editorial Letter that provided an excellent summary of the Guideline’s purpose, scope and intended effects (19).
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<b>Preventing Recurrent Misapplication of the New 2022 CDC Guideline</b>
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According to the Acting Director of the CDC NCIPC, Dr. Christopher Jones, the 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain (hereafter the new Guideline) is not “meant to be implemented as absolute limits of policy or practice by clinicians, health systems, insurance companies, governmental entities (20)." It contains no hard dosing thresholds for prescribing opioids and instead “aims promote equitable access to effective, informed, individualized, and safe pain management that improves patients’ function and quality of life, while clarifying and reducing the risks associated with opioid use (19).” The new Guideline does not apply to patients with pain from sickle cell disease, cancer, or those receiving palliative care and end-of-life care (2, 19), and it cites other clinical guidelines as providing guidance for managing those patients (21-24).
Moving forward, the CDC has pledged to monitor the Guideline’s implementation to prevent recurrent misapplication, but seeks support from a wide coalition of stakeholders to assist with monitoring and advocating against its misapplication (18, 19). Based on the lessons we have learned from our trilogy of Pallimed articles (1, 25, 26), we call on responsible advocates for evidenced-based pain care to join in the important endeavor to restore balance to national opioid policy and preserve the quality of life for patients in pain.
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<b>About the Authors:</b>
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Lead author, Chad Kollas, MD, serves as the Medical Director for Palliative and Supportive Care at the Orlando Health Cancer Institute in Orlando, FL. He can be reached by e-mail at chad.kollas@orlandohealth.com or via Twitter at @ChadKollasMD.
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Bev Schechtman is a patient with chronic illness and pain who has spent the last five years volunteering as a patient advocate. She is currently the Vice-president of The Doctor Patient Forum, and she has been with the volunteer organization, Don't Punish Pain, since its inception in 2017. She is a passionate researcher and advocate who hopes to give a voice to those in pain.
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Carrie Judy is an unpaid contributor and researcher at The Doctor Patient Forum.
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<b>Competing Interests: </b>
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Dr. Kollas as the American Academy of Hospice and Palliative Medicine (AAHPM) Delegate to the American Medical Association (AMA) House of Delegates, where he is the Chair of the AMA Pain and Palliative Medicine Specialty Section Council and a member of the AMA Substance Use and Pain Care Task Force. Dr. Kollas provided testimony at a 2004 Congressional Hearing on OxyContin. Dr. Kollas has served as a medical expert witness in cases involving opinions regarding the standard of care in internal medicine and hospice and palliative medicine. He has received educational research grants from the AMA Education and Research Foundation, Geisinger Clinic and M. D. Anderson Cancer Center Orlando. He serves as the editor for the Advocacy section of AAHPM Quarterly and is a member of the Editorial Advisory Board and review for the Journal of Pain and Symptoms Management. He has also served as a reviewer for the Journal of Palliative Medicine, Annals of Internal Medicine, Journal of General Internal Medicine, Journal of Graduate Medical Education, and the Educational Clearinghouse for Internal Medicine.
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Ms. Schechtman serves as the Vice-president of The Patient Doctor Forum, which accepts donations as a registered 501(c)(3) non-profit organization.
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Ms. Judy serves as a volunteer researchist for The Doctor Patient Forum.
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For more <a href="https://www.pallimed.org/search/label/opioids">Pallimed posts about opioids.</a><br />
For more <a href="https://www.pallimed.org/search/label/kollas">Pallimed posts by Dr. Kollas click here.</a>
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<b>References</b>
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1. Kollas CD, Schechtman B, Judy C. Undisclosed Conflicts of Interest by Physicians Creating the CDC Opioid Prescribing Guidelines: Bad Faith or Incompetence? Pallimed. September 12, 2022. Available at: https://www.pallimed.org/2022/09/undisclosed-conflicts-of-interest-by.html. (Last accessed on October 25, 2022).
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2. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recomm Rep 2022;71(No. RR-3):1–95. DOI: http://dx.doi.org/10.15585/mmwr.rr7103a1.
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3. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1.
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4. Sullivan MD. Long-term opioid therapy unsettles us both coming and going. Pain. 2022 May 1;163(5):807-808. doi: 10.1097/j.pain.0000000000002453. PMID: 34407030. Erratum. PAIN: September 2022 - Volume 163 - Issue 9 - p e1040 doi: 10.1097/j.pain.0000000000002722.
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5. Sullivan MD. Reply to Fields and Darnall. Pain. 2022 May 1;163(5):e690-e691. doi: 10.1097/j.pain.0000000000002519. PMID: 35426891. Erratum. PAIN: September 2022 - Volume 163 - Issue 9 - p e1040 doi: 10.1097/j.pain.0000000000002722.
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6. Personal communication: Francis J. Keefe, Editor-in-Chief, PAIN, e-mail to Chad Kollas, dated May 31, 2022. (Subject: Decision onyour Submission: PAIN-D-22-00416).
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7. The Freedom of Information Act, 5 U.S.C. § 552. Available at: https://www.justice.gov/oip/freedom-information-act-5-usc-552 (Last accessed on November 8, 2022).
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8. Personal communication: Roger Andoh, CDC/ATSDR FOIA Officer, Office of the Chief Operating Officer, Centers for Disease Control and Prevention and Agency for Toxic Substances and Disease Registry (CDC/ATSDR) Freedom of Information Act (FOIA). E-mail to Bev Schechtman, dated October 18, 2022, at 12:20:18 PM EDT (RE: Final Response With Redactions - 22-01939-FOIA).
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9. Sullivan MD, Ballantyne JC. When Physical and Social Pain Coexist: Insights Into Opioid Therapy. Ann Fam Med. 2021 Jan-Feb;19(1):79-82. doi: 10.1370/afm.2591. Epub 2020 Dec 21. PMID: 33355099; PMCID: PMC7800754.
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10. Ballantyne JC, Sullivan MD, Koob GF. Refractory dependence on opioid analgesics. Pain. 2019 Dec;160(12):2655-2660. doi:10.1097/j.pain.0000000000001680. PMID: 31408053.
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11. Manhapra A, Sullivan MD, Ballantyne JC, MacLean RR, Becker WC. Complex Persistent Opioid Dependence with Long-term Opioids: aGray Area That Needs Definition, Better Understanding, Treatment Guidance, and Policy Changes. J Gen Intern Med. 2020 Dec;35(Suppl3):964-971. doi: 10.1007/s11606-020-06251-w. Epub 2020 Nov 6. PMID: 33159241; PMCID: PMC7728942.
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12. Ballantyne JC, Sullivan MD. Intensity of Chronic Pain--The Wrong Metric? N Engl J Med. 2015 Nov 26;373(22):2098-9. doi:10.1056/NEJMp1507136. PMID: 26605926.
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13. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. NCIPC Board of Scientific Counselors Meeting, Friday, July 21, 2021; Atlanta, GA. Available at: https://www.cdc.gov/injury/pdfs/bsc/BSC_NCIPC_Meeting_Minutes_7_16_2021_Final. pdf; see also https://www.youtube.com/watch?v=wb4ysxY0sUo at 0:46 mark. (Last accessed on October 25, 2022).
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14. Chou R, Deyo R, Devine B, Hansen R, Sullivan S, Jarvik JG, Blazina I, Dana T, Bougatsos C, Turner J. The Effectiveness and Risks of Long-Term Opioid Treatment of Chronic Pain. Evid Rep Technol Assess (Full Rep). 2014 Sep;(218):1-219. doi: 10.23970/AHRQEPCERTA218. PMID: 30313000.
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15. Personal communication: Laura Spencer, CDC/ATSDR FOIA Office, Office of the Chief Operating Officer, Centers for Disease Control and Prevention and Agency for Toxic Substances and Disease Registry (CDC/ATSDR) Freedom of Information Act (FOIA). E-mail to Bev Schechtman, dated October 26, 2022, at 4:29 PM EDT.
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16. Personal communication: Ms. Carol Maloney (via Ruhma Sufian), Deputy Agency Chief FOIA Officer U.S. Department of Health and Human Services, Office of the Assistant Secretary for Public Affairs. E-mail to Bev Schechtman, RE: HHS Case No: 2023-00091-FOIA-PHS, dated October 28, 2022, at 1:26:16 PM EDT.
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17. Personal communication: Lisa Robin, Chief Advocacy Officer, Federation of State Medical Boards (FSMB). E-mail to Chad D. Kollas MD, dated September 17, 2022, at 2:11 PM. RE: Speaker Invitation (Workgroup on Opioids and Addiction Treatment, September 27 and 28, 2022, at the Omni Shoreham Hotel in Washington, DC).
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18. Personal Communication: Christopher M. Jones, PharmD, DrPH, MPH, Acting Director, CDC National Center for Injury Prevention and Control (NCIPC). E-mail to Chad D. Kollas MD, dated October 17, 2022, at 1:38 PM. RE: Follow-up from last week’s FSMB Workshop.
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19. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. Prescribing Opioids for Pain - The New CDC Clinical Practice Guideline. N Engl J Med. 2022 Nov 3. doi: 10.1056/NEJMp2211040. Epub ahead of print. PMID: 36326116.
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20. Stone W, Huang P. CDC issues new opioid prescribing guidance, giving doctors more leeway to treat pain. NPR, November 2, 2022. Available at: https://www.npr.org/sections/health-shots/2022/11/03/1133908157/new-opioid-prescribing-guidelines-give-doctors-more-leeway-to-treat-pain (Last accessed on November 7, 2022).
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21. Brandow AM, Carroll CP, Creary S, et al. American Society of Hematology 2020 guidelines for sickle cell disease: management of acute and chronic pain. Blood Adv 2020;4:2656–701. PMID:32559294 https://doi.org/10.1182/bloodadvances.2020001851.
22. Swarm RA, Paice JA, Anghelescu DL, et al.; BCPS. Adult cancer pain, version 3.2019, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw 2019;17:977–1007. PMID:31390582 https://doi. org/10.6004/jnccn.2019.0038.
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23. Tevaarwerk A, Denlinger CS, Sanft T, et al. Survivorship, version 1.2021. J Natl Compr Canc Netw 2021;19:676–85. PMID:34214969 https:// doi.org/10.6004/jnccn.2021.0028.
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24. Paice JA, Portenoy R, Lacchetti C, et al. Management of chronic pain in survivors of adult cancers: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol 2016;34:3325–45. PMID:27458286 https://doi.org/10.1200/JCO.2016.68.5206.
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25. Kollas C. Mandated PROP’s Disproportionate Influence on U.S. Opioid Policy: The Harms of Intended Consequences. Pallimed. May2021. Available at: https://www.pallimed.org/2021/05/props-disproportionate-influence-on-us.html. (Last accessed on November 8, 2022).
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26. Kollas CD, Lewis TA, Schechtman B, Judy C. Roger Chou’s Undisclosed Conflicts of Interest: How the CDC’s 2016 Guideline forPrescribing Opioids for Chronic Pain Lost Its Clinical and Professional Integrity. Pallimed. September 2021. Available at: https://www.pallimed.org/2021/09/roger-chous-undisclosed-conflicts-of.html. (Last accessed on November 8, 2022).
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Christian Sinclairhttp://www.blogger.com/profile/14685043408496367587noreply@blogger.comtag:blogger.com,1999:blog-13495125.post-2677077598984772942022-09-12T11:10:00.009-05:002022-09-13T10:12:49.911-05:00Undisclosed Conflicts of Interest by Physicians Creating the CDC Opioid Prescribing Guidelines: Bad Faith or Incompetence?<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgKI54muav9pWFpKov8zk_2GY42awvzEf1s003HLcyQI0jy3QmAaFCpp5qR9rnQoTSyjGWeIQ9ooisChtdyx0WiAjY9Rf4N1XePQ1hqqx7m49s9822fkU0DusfyepW9_U5T_Oz2cnuVnZ591WMozbfBoObckY2EhmNvt81Kng3KEr3h4V0DjIM/s1080/EAT.png" style="display: block; padding: 1em 0; text-align: center; clear: right; float: right;"><img alt="" border="0" width="320" data-original-height="1080" data-original-width="1080" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgKI54muav9pWFpKov8zk_2GY42awvzEf1s003HLcyQI0jy3QmAaFCpp5qR9rnQoTSyjGWeIQ9ooisChtdyx0WiAjY9Rf4N1XePQ1hqqx7m49s9822fkU0DusfyepW9_U5T_Oz2cnuVnZ591WMozbfBoObckY2EhmNvt81Kng3KEr3h4V0DjIM/s320/EAT.png"/></a></div>
by Chad D. Kollas, MD, Beverly Schechtman and Carrie Judy
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<b>Introduction</b>
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In May 2021, Pallimed published our commentary that described the inappropriate and disproportionate influence given to the advocacy group, Physicians for Responsible Opioid Prescribing (PROP, also known as Health Professionals for Responsible Opioid Prescribing) during the creation process of the Centers for Disease Control and Prevention (CDC) 2016 Guideline for Prescribing Opioids for Chronic Pain, hereafter the 2016 Guideline (1-3). In September 2021, Pallimed published our second commentary, which focused on the astonishing disclosure of an important conflict-of-interest (COI) by Dr. Roger Chou (5), who co-authored the 2016 Guideline, calling its integrity into question (4, 5).
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This commentary, the final in our trilogy, expands on these articles to quantify and clarify the extent of Chou’s COI. We also explore additional COIs from the 2016 Guideline’s creation group before the final release of the updated CDC 2022 Clinical Practice Guideline on Prescribing Opioids for pain, hereafter the 2022 Draft Guideline (6,7). Our results suggest that advocates for unfocused reductions in opioid prescribing propagated a false narrative that physician overprescribing drove increases in overdose deaths over the last two decades. Using this false narrative, these advocates facilitated a corresponding moral panic that produced flawed national opioid policy that has increased drug overdose deaths and harmed patients in pain but has also served the competing financial and intellectual interests of the CDC, health insurers, mass tort litigation attorneys, state attorneys general and anti-opioid stakeholders.
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<b>Background/Chronology</b>
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<i>“Just because you're paranoid doesn't mean they aren't after you (8).”</i>
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In a moral panic, a group of people are portrayed as posing a threat to themselves or society, thereby “justify[ing] intolerance and unfair treatment” of that group, while the “evidentiary standard” for treating them that way is lowered (9, 10). A moral panic can effectively sway public opinion to force a shift in public policy (9-11). “Moral entrepreneurs… crusade for making and enforcing rules that benefit their own interests by bringing them to the attention of the public and those in positions of power and authority under the guise of righting a society [sic] evil ” created by those causing the threat (9, 11). Medicine is not immune to such moral panics, and in the case of opioid policy, patients using opioid analgesics - whether to treat pain or opioid use disorder - became the group posing a “threat to society (9),” while physician advocates for unfocused reductions in opioid prescribing became moral entrepreneurs (9, 10).
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<i>How Did the Media Contribute to this Moral Panic?</i>
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In November 2003, the Orlando Sentinel published a series of articles on OxyContin, exemplifying the media’s moral panic about opioids (12). The series garnered national attention and culminated in the scheduling of a Congressional hearing on the dangers of OxyContin, popularizing the concept of “The Opioid Crisis (13, 14).” Suspicions about the veracity of the articles’ sources triggered an internal investigation, which led to the author’s resignation (15-17), but the series had created a foundation for a false narrative: duped by pharmaceutical companies’ deceptive marketing, physicians allegedly overprescribed opioids to patients with mild pain inappropriately, who eventually died from overdoses after becoming addicted to prescription medications.
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<i>Moral Entrepreneurs Seize the Opportunity</i>
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Opioid prescribing increased during the mid-1990s after widespread calls to improve pain management, particularly at the end of life (18-21). This unexpectedly and undesirably increased health insurers’ medication costs, including Medicare and Medicaid (22). Responding to an underfunded Medicaid program in 2003, Washington State’s Prescription Drug Preferred Drug List “steered people with state-subsidized health care — Medicaid patients, injured workers and state employees — to methadone” as a money-saving choice versus other opioid analgesics (23-25). By 2007, the Washington State Agency Medical Directors Group (AMDG), which included several eventual PROP members (23), published an “Interagency Guideline on Opioid Dosing for Chronic Non-Cancer Pain (26) that introduced the concept of hard dosing thresholds for opioid analgesics, which was later incorporated into the 2016 Guideline (2, 3). Although this reduced Washington state’s Medicaid costs, it contributed “to the deaths of at least 2,173 people between 2003 and late 2011 (23, 25).”
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Despite these deaths, the false narrative gained traction and clarity when it was advanced by Andrew Kolodny, who co-authored a 2011 article with Roger Chou which announced the formation of the physician advocacy group, Physicians for Responsible Opioid Prescribing or PROP (26). Kolodny further asserted that physicians “contributed to an epidemic of overdose deaths and addiction by overprescribing opioids (27, 28).” PROP and Chou petitioned the Food and Drug Administration (FDA) to change opioid labeling in July 2012 (29, 30), but FDA rejected PROP’s call for a maximum daily dose of opioid analgesia of 100 morphine milligram equivalents (MME) based on a lack of supporting data (31).
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<i>The 2016 Guideline, Its Misapplication and Patient Harms</i>
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In the CDC, PROP found a more willing collaborator than FDA during the formation of the 2016 Guideline, prompting numerous concerns about the transparency and flawed integrity of its creation process (1, 4, 32-34). For example, in late 2015, Washington Legal Foundation alleged that one of the members of CDC’s Core Expert Group (later identified as PROP member, Jane Ballantyne) had “served as a paid consultant to a law firm planning multi-district litigation against opioid manufacturers (4, 33, 34).” WLF’s complaint compelled the CDC to re-open a second open comment period for the public, lasting 30 days in duration, rather than the two-day period for comment which CDC had originally presented via a September 2015 webinar (4, 35).
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Despite transparency concerns and worries about conflicted interests on the part of the Guideline’s creators by key stakeholders (36-39), CDC published its 2016 Guideline on March 18, 2016 (2-4). That same month, Kolodny – who had served as a Stakeholder Reviewer for the 2016 Guideline - deflected concerns about PROP members’ relationships with law firms suing opioid manufacturers (34) and instead characterized key stakeholders’ open comments to CDC as driven by “financial relationships with opioid manufacturers (40).”
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By November 2018, misapplication of the 2016 Guideline had begun to cause serious patient harms, including diminished access to medically appropriate opioid analgesia (41). Moreover, a group of CDC scientists publicly questioned the accuracy of CDC data on drug overdose deaths, which had not accounted for deaths involving illicit fentanyl (42). In response, the American Medical Association (AMA) called against widespread misapplication of the 2016 Guideline, including its embrace of hard dosing thresholds (1, 43). Other stakeholders quickly joined AMA’s call against misapplying the 2016 Guideline (44-47), and in April 2019, the Guideline’s co-authors acknowledged its widespread, including “inflexible application of recommended dosage and duration thresholds and policies that encourage[d] hard limits and abrupt tapering of drug dosages, resulting in sudden opioid discontinuation or dismissal of patients from a physician’s practice (48, 49).” That same month, FDA posted a public safety announcement warning against sudden discontinuation of opioid medications (1, 50), supplemented by a podcast warning against rapid opioid tapers (51). CDC issued another public warning against misapplication of the 2016 Guideline on April 24, 2019 (52).
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<i>Moral Entrepreneurs Undermine a Call for Balanced Opioid Policy </i>
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Just a few months earlier, a new hope for balanced opioid policy had emerged via the U.S. Department of Health and Human Services (HHS) Inter-Agency Task Force Draft Report on Pain Management Best Practices (53, 54). Pain management experts felt that the HHS Draft Report would “improve the access to pain care and remove the stigma, providing patients and providers with appropriate education, training, risk assessment, and evaluation (55).”
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Opposing that view, however, the National Association of Attorneys General (NAAG) sent comments to HHS Assistant Secretary for Health, Dr. Vanila Singh, encouraging HHS not to move away “from key components of the CDC Guideline for Prescribing Opioids for Chronic Pain,” citing concerns that doing so “would undermine ongoing legislative initiatives [and] refinements to standards of medical care (56).” PROP hypocritically criticized the HHS Draft Report, noting that “HHS should have excluded individuals and organizations with financial ties to opioid manufacturers from serving on the HHS Pain Management Task Force (57).” The HHS Draft Report on Pain Management Best Practices quietly faded into obscurity.
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<i>Reassessing the 2016 Guideline; Creating the 2022 Opioid Guideline</i>
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As part of a planned assessment process, CDC opened a docket for public comments on its 2016 Guideline in April 2020 (58). Key stakeholders again expressed concerns about growing patient harms arising from the Guideline’s misapplication, especially from nonconsensual opioid tapers and denials for pain care, which amplified calls to rescind hard dosing thresholds (59, 60). In contrast, PROP predicted “the downward trends in new starts of chronic opioid treatment achieved by the 2016 guideline should be seen as a positive development that will encourage people to find alternative means of controlling chronic pain, which… will ultimately result in better outcomes and less distress (61).” Despite PROP’s optimism, CDC observed that “age-adjusted overdose death rates involving synthetic opioids, psychostimulants, cocaine, heroin, and prescription opioids during 2013–2019” increased 1,040%, largely as the result of illicit fentalogues (62-64). PROP deflected this news by criticizing AMA’s opioid policy as tainted by contributions from the pharmaceutical industry (65, 66).
<br><br>
When Roger Chou unexpectedly disclosed his conflict of interest (COI) from receiving “funding to conduct reviews on opioids (4, 5),” evidence of harms from misapplications of 2016 Guideline had become more apparent (67-73). In the wake of Chou’s admission, the CDC 2022 Opioid Work Group (OWG) expressed additional concerns about the 2022 Draft Guideline, including that it was “not balanced and missing key studies” about potential opioid benefits and contained a constant tension between “public health benefits [versus] patient benefits (74).” The OWG also cited concerns about “including specific opioid dose thresholds in the recommendations” in the 2022 Draft Guideline (74). In light of the OWG’s concerns, we explored the depth of Chou’s COI disclosure (4, 5) and sought to uncover any other relevant, unreported COIs by those who created the 2016 Guideline and shaped current U.S. opioid policy.
<br><br>
<b>Methodology</b>
<br><br>
We qualitatively explored undisclosed or omitted conflicts of interests (COIs) from journal articles authored by the group of physicians who had advocated publicly, mainly through their PROP-related activities, for reduced opioid prescribing before their selection into the creation group of the 2016 Guideline. We examined whether they excluded disclosures of relevant COIs in publications that could influence opioid policy, emphasizing articles that might have prejudiced the creation process for the 2022 Draft Guideline.
<br><br>
We identified relevant publications via a query of PubMed (via the website link, https://pubmed.ncbi.nlm.nih.gov/) using the authors’ names and the search terms “CDC,” “Tapers,” “MME,” “Opioid Treatment,” or “Opioid Epidemic” for the period between September 1, 2015 and June 30, 2022. This start date reflected the timing of CDC’s webinar for its intended release of its 2016 Guideline (2, 3), while the end date preceded a decision by CDC on the final form for its 2022 Revised Opioid Guideline (6, 7). We included articles that articulated policy positions or recommendations relevant to either the 2016 Guideline or 2022 Draft Guideline. These articles contained key themes arising from discourse about the Guidelines, including but not limited to opioid tapering, MME, dosing thresholds and/or opioid prescribing recommendations. We called articles that met these inclusion criteria, “qualifying policy articles (QPAs).” Articles that focused on opioid use disorder or its treatment, acute pain management, or that made no recommendations about opioid treatment or U.S. policy were excluded from the analysis.
<br><br>
We defined “conflict of interest” using the methodology used by CDC itself in its creation of the 2016 Guideline, which “asked potential experts to reveal possible conflicts of interest such as financial relationships with industry, intellectual preconceptions, or previously stated public positions (2).” This included financial and non-financial or intellectual conflicts or competing interests. It also called for the exclusion of any experts that had “conflicts that might have a <i>direct and predictable effect on the recommendations</i> (2, italics ours),” such as taking a public position (such as signing a petition) or making recommendations intended to affect opioid policy. Additionally, we defined the authors’ role within relevant advocacy organizations based on their own statements of membership, or by virtue of their authorship of, or signature on, a supporting a policy document advocating for an opioid policy position.
<br><br>
<b>Results</b>
<br><br>
Table 1 summarizes the undisclosed or omitted conflicts of interest of the study group physicians, who advocated for reduced opioid prescribing prior to their involvement in the creation of the 2016 Guideline (2, 3). In sixty-three of 87 QPAs (72%), these physicians omitted or failed to disclose conflicts of interest (COIs) as defined by the 2016 Guideline (5). Three of these physicians (GF, DT and LN) failed to disclose relevant COIs in all their QPAs, and one physician (JB), failed to disclose COIs in 84% of her QPAs. Only one physician (RC) fully disclosed all COIs in more than half of his QPAs.
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<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgQ9bbl1nJjz9YraOn5tyaJs-odtsRSeKDusLpeUUyUDmQbIG1QeyizEgGur58TlnH8S7t7XNinVizgs0RC7i3rygAIywUfJtWKBu6LsSGoBifDIlguIWLLBe-FMHIZQ8W4ow1fBAerZhrqDCUFCQ1DTpxNMxM9eerLMVw3olRj2oEachNSkHo/s1467/table%201.png" style="display: block; padding: 1em 0; text-align: center; "><img alt="" border="0" width="600" data-original-height="855" data-original-width="1467" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgQ9bbl1nJjz9YraOn5tyaJs-odtsRSeKDusLpeUUyUDmQbIG1QeyizEgGur58TlnH8S7t7XNinVizgs0RC7i3rygAIywUfJtWKBu6LsSGoBifDIlguIWLLBe-FMHIZQ8W4ow1fBAerZhrqDCUFCQ1DTpxNMxM9eerLMVw3olRj2oEachNSkHo/s600/table%201.png"/></a></div>
<br><br>
Table 2 lists the physicians’ most frequently cited QPAs and relevant conflicts of interest. As a group, four of six physicians (67%) omitted or failed to disclose both financial and intellectual (non-financial) COIs, while two of six physicians had intellectual COIs only. At the time of their selection to the 2016 Guideline creation group, each of the six physicians had an existing intellectual COI (4, 27, 29, 33) and two (RC and JB) had existing financial COIs (3, 4, 33, 34), although these COIs were identified only <i>after</i> they had contributed to the Guideline’s creation process.
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<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi3KVhI617p1lp810qzj00eNSybH3qbSyubM6SFwXI1YmrXdLTeO7kIU_1mw8RIqqT5DMgzlx7JnNobJyTNQhUmlITDcVvqbI47OEX9K1tPkw36gl_5MYgmXJR0Mbx2A91vTc-xY6Zedmann9UP-chaT0hjThjUkx1FYtqlmqh2vy-cv-PFKos/s1710/Table%202.png" style="display: block; padding: 1em 0; text-align: center; "><img alt="" border="0" width="600" data-original-height="659" data-original-width="1710" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi3KVhI617p1lp810qzj00eNSybH3qbSyubM6SFwXI1YmrXdLTeO7kIU_1mw8RIqqT5DMgzlx7JnNobJyTNQhUmlITDcVvqbI47OEX9K1tPkw36gl_5MYgmXJR0Mbx2A91vTc-xY6Zedmann9UP-chaT0hjThjUkx1FYtqlmqh2vy-cv-PFKos/s600/Table%202.png"/></a></div>
<br><br>
<b>Discussion</b>
<br><br>
<i>Conflict Overview, Ethics and CDC’s Guiding Principles</i>
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The Institute of Medicine (IOM) has defined a conflict of interest as “a set of circumstances that creates a risk that professional judgment or actions regarding a primary interest will be unduly influenced by a secondary interest (107).” IOM has noted that “expert judgment based on clinical experience remains a significant element in the development of evidence-based practice guidelines,” and recommended that “groups that develop clinical practice guidelines should generally exclude as panel members individuals with conflicts of interest (107).” The American College of Physicians (ACP) recently echoed this sentiment, noting, “One of the hallmarks of a trustworthy clinical guideline or guidance statement is a comprehensive process for disclosure of interests (DOI) and management of conflicts of interest (COIs) (108).” ACP also emphasized that participants creating clinical guidelines should “disclose all active and inactive financial and intellectual interests related to health care,” noting that intellectual COIs “may leave a clinical guideline vulnerable to cognitive biases and may result in indirect financial benefit related to career advancement (108, 109).” Additionally, a Guideline Panel Review working group commissioned by the British Medical Journal (BMJ) identified “red flags” to raise “substantial skepticism” about clinical guidelines’ credibility (110). These “red flags” include any financial conflict by the committee chair, multiple panel members with financial conflicts and “any suggestion of committee stacking that would pre-ordain a recommendation regarding a controversial topic (110).”
<br><br>
Taking these position statements into account, our results suggest that the physicians from this study group have undermined the integrity of both the 2016 Guideline and 2022 Draft Guideline through their PROP- and MDL-related undisclosed or omitted COIs. We have applied CDC’s own ethics and guiding principles to identify these COIs, beginning with its definition of COIs from rules for creating the 2016 Guideline (2, 3). CDC has asserted that “users of guidelines and recommendations need to feel confident that those participating in the development process were not unduly influenced by personal interests. Minimizing competing interests among members of steering committees and technical groups improves guideline acceptability, credibility, and scientific rigor (111).” CDC acknowledged that “a participant with a competing interest might be excluded from participating in the development of the final recommendation statement (111),” and that “guideline developers should make every effort to either eliminate or manage financial, intellectual, or professional interests that compete with the goals of producing an evidence-based guideline (111).” Furthermore, CDC policy states that “reviewers must provide written assurance that their reviews are free of real or perceived conflicts of interest (112)”, and “scientists having <i>real or perceived conflicts of interest</i> with the applications under review may not attend or participate in initial peer review or secondary review meetings (112; italics ours).” Since HHS ethical rules allow obtaining a waiver if an “individual’s services [to an advisory committee] outweigh the potential for a conflict of interest created by the particular financial interest involved (113),” we have submitted a Freedom of Information Act (FOIA) request to CDC to view the waivers of the members of study group (JB, RC, DJ and AK) with financial COIs (see Table 2), the outcome of which is pending at this time (114).
<br><br>
<i>COI Overview and Key Individual Conflicts</i>
<br><br>
All authors should disclose all relevant financial and non-financial or intellectual COIs when creating clinical guidelines intended to influence health policy. In a 2012 study of 114 clinical guidelines created by medical specialty societies (115), COIs were disclosed for 71% of committee chairpersons and 91% of co-chairpersons, which still led to criticism about their trustworthiness for falling short of complete disclosure (116). The physicians in this study group had an overall COI disclosure rate of just 28% in QPAs, which should raise serious concerns about their credibility in matters of health care policy.
<br><br>
While Roger Chou omitted COIs in just 40% of QPAs in this study, he omitted disqualifying financial and intellectual conflicts at the time of his co-authorship of both the 2016 Guideline and the 2022 Draft Guideline (3, 27, 29, 85-91). At the time of his authorship of the 2016 Guideline, Chou did not disclose his pending funding from the Agency for Healthcare Research and Quality (AHRQ) for writing systemic reviews on opioid prescribing, although the grant award was not announced publicly until after its publication (85-91). The National Foundation for the Centers for Disease Control and Prevention, also known as the CDC Foundation, “an independent, private, nonprofit organization chartered by Congress in 1995 and classified as a 501(c)(3) public charity (117),” and AHRQ have both received funding from Group Health that supported Chou’s systemic reviews of opioids (4, 23). Chou’s competing interests should have mandated restriction “from further involvement in development of the clinical guideline… [including] participation in discussions, voting on recommendations, and authorship, or he or she may resign from the committee (108).” Chou did not resign from either the 2016 Guideline or 2022 Draft Guideline creation groups, nor did he step away from authorship, even after disclosing his financial COI publicly (4,5). Several stakeholders commented on these disqualifying COIs during the Open Period for comments on the 2022 Draft Guideline (118-121), but CDC created confusion by redacting Chou’s identity from many of these comments (122) despite public knowledge of his co-authorship of both Guidelines (122).
<br><br>
In addition to Chou’s egregious funding omission, Jane Ballantyne failed to report COIs in 84% of QPAs, while serving as a section editor for a well-known medical journal (123). As an editor, she understood well the ethical principles for reporting competing interests in medical journals (123-125). Furthermore, Ballantyne’s PROP colleague and frequent co-author, Mark Sullivan, recently failed to report his opioid litigation expert witness work as a COI in articles about opioid tapering policies in the journal which she serves as an editor (81, 126), including an article on which she “provided comments on an earlier draft (127).” When notified about the COI in a submitted editorial letter, the journal’s editor-in-chief pledged to publish a correction, but rejected the letter for publication, avoiding publicization of Ballantyne’s ethical violation (128). This correction has not been posted to date (126, 127). Similarly, Sullivan failed to disclose the same conflict in a letter to a medical journal that he co-authored with Ballantyne in March 2021 (129). Rather than publishing an editorial letter identifying the undisclosed COI, however, the article was updated to include the previously unreported competing interest (130). To date, identifying Ballantyne’s failure to disclose these omitted COIs has not affected her status as a section editor for the journal (123).
<br><br>
By contrast, Andrew Kolodny has published three QPAs since September 2019 (131-133), after he corrected his COI disclosures for JAMA articles from 2017 and 2018 (102-105). In more recent QPAs, Kolodny has consistently disclosed COIs arising from his PROP membership and expert witness work for multidistrict litigation (MDL) against opioid manufacturers and distributors (131-133). Unlike Ballantyne’s case, Annals of Internal Medicine posted a comment that revealed that a co-author on one of Kolodny’s QPAs (99) failed to disclose a relevant COI in an opioid policy article (134-136). While Kolodny’s recent reappointment as the president of PROP suggests that disclosing his more recent COIs has not restricted his aggressive advocacy (137), it is unclear whether that has affected the outcome of two recent MDL cases in which he testified for the plaintiffs (138, 139).
<br><br>
<i>Does Disclosing COIs Matter?</i>
<br><br>
The lack of consequences for omitting relevant COIs from QPAs in our study and the failure of many clinical practice guidelines to conform to standards for disclosing COIs (107-117) begs the question of whether disclosing COIs in medical journal articles even matters. Again, the answer comes from the CDC itself: “Guidelines, unlike some types of policies, are not mandatory. In health care and public health, guidelines are not meant to enforce but rather to recommend programs or practices based on the best evidence available. Often, however, CDC and others’ guidelines become ‘the standards of practice,’ unintentionally acquiring the force of policy (111). Users of guidelines and recommendations need to feel confident that those participating in the development process were not unduly influenced by personal interests. Minimizing competing interests among members of steering committees and technical groups improves guideline acceptability, credibility, and scientific rigor (111). Each release of a new CDC guideline might have a lasting impact on clinical and public health practice. Guidelines may be converted to policy, implying widespread implementation by a broad range of groups. <i>Guidelines may be even converted into law</i>, entailing subsequent regulatory enforcement (111; italics ours).”
<br><br>
Ironically, Roger Chou lamented this conversion of the 2016 Guideline into law because of its misapplication <i>in the very same article in which he failed to disclose his funding for writing the systemic reviews upon which he based the both the Guidelines</i> (4, 5, 23, 48, 85, 86). Accurate disclosures of COIs matter because the “public trust in the scientific process and the credibility of published articles depend[s] in part on how transparently an author's relationships and activities, directly or topically related to a work, are handled during the planning, implementation, writing, peer review, editing, and publication of scientific work (125).”
<br><br>
<i>Following the Money</i>
<br><br>
Advocates for reduced opioid prescribing have enjoyed an advantage from the failure of regulatory agencies and medical journals to identify and publicize relevant COIs, thereby propagating moral panic and the false narrative that overprescribing drives the opioid overdose deaths (27, 28). These deaths arose from an epidemic of poisonings from multiple illicit substances, including counterfeit drugs and ethanol, rather than from prescription opioids (42, 140-145). Knowing this, why have federal regulatory agencies and advocates for reduced opioid prescribing cling to a demonstrably false narrative about overprescribing?
<br><br>
As the saying goes, “Follow the money (146).” We described above how changes in opioid policy aimed at reducing Washington State’s Medicaid and Workers Compensation costs contributed to an increase in methadone deaths between 2003 and late 2014 (23-25). Focusing on similar cost reductions, the Centers for Medicare and Medicaid Services (CMS) proposed rules for 2019 including several directives intended to reduce "Opioid Overutilization,” including adoption of the “90 morphine milligram equivalent (MME) threshold cited by the 2016 CDC Opioid Guideline (147, 148). Simply put, reduced prescribing reduces costs for prescribed medications.
<br><br>
Chou received research funding to write systemic reviews of opioid analgesics that shaped both Guidelines, but largely ignored opioids’ potential benefits; he again failed to cite that funding when writing an article bemoaning early harms from the 2016 Guideline’s misapplication (3-5, 48, 74, 85-91). Employing a model created by the tobacco settlements of the 1990s (149), state, federal and local governments have successfully used the 2016 Guideline to justify their legal arguments in settlements of multidistrict litigation (MDL) suits against opioid manufacturers and distributors (150-153). Legal experts’ concerns about Ballantyne’s and Kolodny’s participation in the Guideline’s creation, during which they received financial compensation for MDL-related expert witness work (4, 23, 33, 34, 81-84, 99-105), proved correct when plaintiffs used the 2016 Guideline as a tool to support MDL lawsuits (37, 38, 154).). Andrew Kolodny openly anticipated making $500,000 from his expert witness work on Oklahoma’s lawsuit against opioid manufacturers and distributors (137, 155), while Ballantyne has never disclosed the amount of her personal fees from Motley Rice LLP, “one of the Nation's Largest Plaintiffs' Litigation Firms” and an MDL litigant (156, 157).
<br><br>
As of July 31, 2022, awards from opioid MDL lawsuits settlements had totaled more than <i>$36 billion</i>, with more suits still pending nationwide (158). Many policymakers have called for this settlement money to be spent fortifying public health (159), but tensions have emerged about “what interventions and treatments should be funded (160).” While it remains unclear how much the public will benefit from these settlements, it is very clear that plaintiff expert witnesses from our study group comprise one of the major financial beneficiaries of the MDL lawsuits.
<br><br>
<i>Limitations and Criticisms</i>
<br><br>
When creating our methodology, we purposely borrowed from Kolodny’s methodology (40) to disarm anticipated criticism by PROP and its allies. Similarly, when seeking publication, we received confidential criticism that we self-referenced our prior works in the same way that the study group’s references one another’s work to justify their opioid policy positions. To this we reply, “Turnabout is fair play (161).” Our study examines only physician advocates who served a role in creating the 2016 Guideline. Many more physicians have advocated for open-ended reductions in opioid prescribing and have omitted COIs in journal articles involving opioid policies (126-130, 132, 135), but have not been included in this commentary, because of our intentional limitation on its scope. Finally, we did not identify any participants in the creation process of the 2016 Guideline who possessed “conflicts that might have a direct and predictable effect on the recommendations” related to policy positions supporting medically appropriate opioid prescribing.
<br><br>
<b>Concluding Recommendations</b>
<br><br>
Our results strongly suggest that CDC disregarded or disobeyed its own rules and ethical guidelines (111-113) by allowing PROP members and allies to help create the 2016 Guideline, thereby compromising its ethical integrity (1, 4, 23, 34, 36, 119-123). Those physicians acted entrepreneurially to facilitate a moral panic (9-11) about opioid-involved overdose deaths, using a false narrative about overprescribing that successfully changed opioid policy nationally. These policies have unacceptably increased risks of harm for patients in pain (43-45, 48-52, 67-73). Unfortunately, abolishing or repealing the 2016 Guideline and 2022 Draft Guideline, while ethically justifiable, now seems like an impossible task. The federal government has invested too much time and too many resources into the Guidelines to abandon them, especially while MDL suits against opioid manufacturers and distributers are still pending.
<br><br>
What can be done to undo the harms created by the 2016 Guideline and prevent further harm from the 2022 Draft Guideline? We strongly recommend abolishing hard dosing thresholds from the 2022 Draft Guideline, because their misapplication has emboldened involuntary and/or rapid opioid tapers, contributing to patient harms (43-45, 48-52, 67-73). These hard dosing thresholds have been improperly translated into “mandatory policies and laws throughout the country, becoming, in effect a standard of care used by states, payers, pharmacy benefit plans, health care systems and providers (162).” Next, while the 2022 Draft Guideline offers some improved language toward that goal, CDC must unequivocally denounce the false narrative that overprescribing still drives the opioid crisis, as “the particular focus around reduced opioid prescribing has met with limited success and contributed to subsequent waves of the crisis (163).” CDC’s Opioid Workgroup for the 2022 Draft Guideline cited similar concerns about hard dosing thresholds, but also acknowledged the inherent tension between patient versus public or societal health benefits (74). In addition, we call on policymakers to correct the current policy imbalance between patients’ medical autonomy and society’s benefit, acknowledging that physicians have an individualized, fiduciary duty to act in their patients’ best interests which may sometimes reasonably conflicts with public health goals (164). Patients are not monoliths, and physicians cannot treat them individually using a broad policy brush. Physicians’ primary responsibility is to attend the individualized needs of the patients they are treating. Thus, we envision creating an ethics-based, education-focused informed consent process that allows patients to weigh treatment risks versus potential benefits collaboratively to enhance opioid prescribing safety (165).
<br><br>
Furthermore, we identified a 72% rate of nondisclosure of COIs in our study group, which we find ethically unacceptable, considering the purported importance of transparency when creating clinical guidelines (107-110). CDC itself has acknowledged this moral imperative, but hasn’t adhered to its own ethical rules (111-113). Given the apparent inability of the study group authors and the CDC to transparently self-regulate the conflict disclosure process, we encourage medical journals to become more vigilant about identifying authors’ financial and intellectual COIs in submitted manuscripts about opioid policies. This includes holding editors accountable when they deliberately ignore relevant competing interests (123, 126-128).
<br><br>
Finally, if these recommendations fail to restore balanced U.S. opioid policy, we call upon the U.S. House Committee on Oversight and Government Reform to convene a hearing to scrutinize CDC’s use of a Core Expert Group to write its opioid guidelines instead of complying with the supervisory requirements of Federal Advisory Committee Act (166). Alternatively, we would invite the U.S. Department of Justice to investigate why CDC has repeatedly violated internal rules and ethical policies while creating the 2016 Guideline and 2022 Draft Guideline (111-113). Permitting ongoing patients harms from these Guidelines desecrates the sacred trust between prescribing physicians and patients afflicted by chronic pain.
<br><br>
<b>Dedication:</b>
<br><br>
This commentary is dedicated to the memory of Dr. Terri Lewis, a beloved colleague and tireless advocate for patients with disabilities and chronic pain.
<br><br>
<b>About the Authors:</b>
<br><br>
<i>Lead author, Chad Kollas, serves as the Medical Director for Palliative and Supportive Care at the Orlando Health Cancer Institute in Orlando, FL. He can be reached by e-mail at chad.kollas@orlandohealth.com or via Twitter at @ChadKollasMD.
<br><br>
Bev Schechtman is a patient with chronic illness and pain who has spent the last five years volunteering as a patient advocate. She is currently the Vice-president of The Doctor Patient Forum, and she has been with the volunteer organization, Don't Punish Pain, since its inception in 2017. She is a passionate researcher and advocate who hopes to give a voice to those in pain.
<br><br>
Carrie Judy is an unpaid contributor and researcher at The Doctor Patient Forum.</i>
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<b>Competing Interests</b>:
Dr. Kollas recently served as Secretary on the Board of Directors of the American Academy of Hospice and Palliative Medicine (AAHPM). He also serves as the AAHPM Delegate to the American Medical Association (AMA) House of Delegates, where he is the Chair of the AMA Pain and Palliative Medicine Specialty Section Council and a member of the AMA Substance Use and Pain Care Task Force. Dr. Kollas provided testimony at a 2004 Congressional Hearing on OxyContin. Dr. Kollas has served as a medical expert witness in cases involving opinions regarding the standard of care in internal medicine and hospice and palliative medicine. He has received educational research grants from the AMA Education and Research Foundation, Geisinger Clinic and M. D. Anderson Cancer Center Orlando. He serves as the editor for the Advocacy section of AAHPM Quarterly and is a member of the Editorial Advisory Board and review for the Journal of Pain and Symptoms Management. He has also served as a reviewer for the Journal of Palliative Medicine, Annals of Internal Medicine, Journal of General Internal Medicine, Journal of Graduate Medical Education, and the Educational Clearinghouse for Internal Medicine.
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Ms. Schechtman serves as the Vice-president of The Patient Doctor Forum, which accepts donations as a registered 501(c)(3) non-profit organization.
<br><br>
Ms. Judy serves as a volunteer researchist for The Doctor Patient Forum.
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For more <a href="https://www.pallimed.org/search/label/opioids">Pallimed posts about opioids.</a><br />
For more <a href="https://www.pallimed.org/search/label/kollas">Pallimed posts by Dr. Kollas click here.</a>
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<b>References</b>
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1. Kollas C. Mandated PROP’s Disproportionate Influence on U.S. Opioid Policy: The Harms of Intended Consequences. Pallimed. May 2021. Available at: https://www.pallimed.org/2021/05/props-disproportionate-influence-on-us.html. (Last accessed on August 11, 2022).
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12. Bloodsworth D. Pain Pill Leaves Death Trail. Orlando Sentinel, October 19, 2003. Available at https://www.orlandosentinel.com/news/os-xpm-2003-10-19-0310190446-story.html. (Last accessed on August 11, 2022; access may be limited by pay wall).
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13. Bloodsworth D. Congress Tackles OxyContin: Legislators’ 1st Hearing Will be in Orlando in February. Orlando Sentinel, December 5, 2003.
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14. To Do No Harm: Strategies for Preventing Prescription Drug Abuse. Hearing Before the Subcommittee on Criminal Justice, Drug Policy and Human Resources, Committee on Government Reform, 108th Congress, 2nd Session. February 9, 2004, Winter Park, FL. Available at https://www.govinfo.gov/content/pkg/CHRG-108hhrg95555/html/CHRG-108hhrg95555.htm. (Last accessed on August 11, 2022).
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15. Bloodsworth D. OxyContin maker says patient is not credible: Ex-cop profiled had drug-related conviction. Orlando Sentinel, February 5, 2004.
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16. Personal communication: Chad Kollas e-mail to Orlando Sentinel Editor, Manning Pynn, dated Monday, February 23, 2004 at 10:44 AM.
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Christian Sinclairhttp://www.blogger.com/profile/14685043408496367587noreply@blogger.comtag:blogger.com,1999:blog-13495125.post-9482722128501346082022-07-11T15:00:00.003-05:002022-07-11T15:25:37.779-05:00Celebrating Hospice and Palliative Medicine as the Fifth Largest Medical Subspecialty<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgcBpJeiO3ne039k5qNPh5uodgOnj-28IBWa4IaHnYLZnCxBaoH61OKZ_D18u3No7ORgVEytkrTB2RE5O-ay_iDYG2JGRMbHxlC2Uj9BQrt4j60CcPZ7OQn_IImXApE9gI7gvzZsffUJV7sciN-Iyif6ziR9YPpCUPx4UHJXfziPZMdpFtsPSg/s800/football%20quality.png" style="display: block; padding: 1em 0; text-align: center; clear: right; float: right;"><img alt="" border="0" width="320" data-original-height="800" data-original-width="800" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgcBpJeiO3ne039k5qNPh5uodgOnj-28IBWa4IaHnYLZnCxBaoH61OKZ_D18u3No7ORgVEytkrTB2RE5O-ay_iDYG2JGRMbHxlC2Uj9BQrt4j60CcPZ7OQn_IImXApE9gI7gvzZsffUJV7sciN-Iyif6ziR9YPpCUPx4UHJXfziPZMdpFtsPSg/s320/football%20quality.png"/></a></div>
by Christian Sinclair (<a href="https://twitter.com/ctsinclair" target="_blank">@ctsinclair</a>)
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We have entered a new age! Spread the word! <b>Hospice and palliative medicine (HPM) is the fifth largest medical subspecialty!</b>
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You may have sensed we have been climbing the ranks, but I bet you are still surprised. A close look at the fellowship match data from Dec 2021, shows that HPM has the fifth highest number of matched applicants, behind the big 4: Cardiovascular, Pulmonary and Critical Care, Hematology and Oncology, and Gastroenterology.
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When I share this good news with HPM colleagues, few put us anywhere near fifth. <a href="https://twitter.com/ctsinclair/status/1515374683746672645?s=20&t=jCF-1rvwgrFYry6uXToRSQ" target="_blank">I did an informal poll on Twitter</a> and less than half of respondents ranked HPM in the top 10. Of those that did rank HPM, the average rank was 7. Clearly, we are not telling our own story very well.
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There are many possible reasons to feel skeptical, but yes, <b>HPM is the fifth largest medical subspecialty!</b> Yet, it still may not feel like that...why might that be? In general, I find HPM clinicians to be a humble, cordial bunch. <a href="https://www.pallimed.org/2019/02/introversion-and-hospice-palliative.html" target="_blank">We may be more introverted</a>. We are not ones to generally boast about our accomplishments as a field. Most of that attention is often dedicated to some new technology or medicine anyway.
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Also, maybe we percieve oursleves to be a smaller specialty because access to HPM physicians is still highly variable. Centered in metro areas and more likely to be found wandering the halls of academia, there may be local, regional or organizational reasons why HPM has a smaller footprint in one place, while being a driving force in another. A message can be muddled when telling a large audience to access HPM physicians yet there are none in their area.
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Additionally, we are still quite a young specialty, with the <a href="https://www.pallimed.org/2005/06/pallimeds-first-post-good-news.html" target="_blank">birth of HPM as an official specialty being announced in 2005</a>, and getting started in 2008. We have just entered our teenage years. Maybe it is OK to think about ourselves for a bit, and test the boundaries of our newfound confidence like any respectable teenager.
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Lastly, many are working in health care organizations which still treat <a href="https://pubmed.ncbi.nlm.nih.gov/33855886/" target="_blank">palliative medicine and hospice physicians as “nice to have” instead of “essential.”</a> It is hard to feel like you are part of a larger group when there are not many colleagues around you. The teams we work with may still feel empty without all the key disciplines collaborating. A HPM physician is a good start, but when there are no resources, no infrastructure and not enough people to get the work done, HPM may be limited to being little more than a glossy brochure.
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So why do we need to talk about this? Because this is a great opportunity to increase visibility which can help in a variety of ways. The message is simple, <b>HPM is the fifth largest medical subspecialty!</b> We are right behind cardiologists, oncologists, critical care and GI and this should be something (when shared) helps to cement our stature. <a href="https://twitter.com/ctsinclair/status/1517161508526084096" target="_blank">When you are number five, we should not settle for being relegated to choosing ‘other’ on a list of medical subspecialties. </a> If rheumatology is on there, so are we. If geriatrics is on there, so are we. If infectious disease is on there, so are we.
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Sharing this message increases our visibility at our own organizations. We should be including this in our presentations on Hospice and Palliative Medicine 101, or frankly anytime we are asked to speak to outside audiences. We need to share this on social media and in conversations with our colleagues, friends and family. People should want to understand what hospice and palliative medicine doctors do, especially when <b>HPM is the fifth largest medical subspecialty.</b>
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We are currently in fellowship application season, so this is a message to share when people come to your program. This increased national visibility will also help bring more people to our field with fresh ideas, diverse backgrounds, and new skills. We have important areas to grow with HPM physicians playing an important part including outpatient and community care, hospice care, pediatrics, and research. Right now, we are not filling all of our fellowship slots (85% filled) and we have a looming HPM physician shortage. What a great time to be popular and <a href="https://www.pallimed.org/2018/09/the-future-of-hospice-and-palliative.html" target="_blank">get the word out to pre-med students, med students and residents of all primary specialties to put HPM onto their short list</a>. It will be hard to act surprised when learners declare an interest in palliative care, because after all, <b>HPM is the fifth largest medical subspecialty.</b>
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I am still surprised this Tweet happened as recently as 2018!
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<blockquote class="twitter-tweet"><p lang="en" dir="ltr">Attending: "What specialty are you thinking of?"<br>Me: "<a href="https://twitter.com/hashtag/Palliative?src=hash&ref_src=twsrc%5Etfw">#Palliative</a>"<br>Attending: "No one has ever said that answer before."<br><br>Give me a couple years. I'm rounding up some troops! <a href="https://twitter.com/hashtag/hpm?src=hash&ref_src=twsrc%5Etfw">#hpm</a></p>— Kayla Sheehan, MD (@kksheehan) <a href="https://twitter.com/kksheehan/status/1021233008840339457?ref_src=twsrc%5Etfw">July 23, 2018</a></blockquote> <script async src="https://platform.twitter.com/widgets.js" charset="utf-8"></script>
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I do not expect that to happen in the future. The more we share the growth of our field, that we are here, that we have numbers, that we are strong, and that we will make an impact, then we can reserve OUR seat at the table to make the important decisions shaping the future of health care. I hope you are thinking of the first person you need to tell that <b>HPM is the fifth largest medical subspecialty.</b> Let’s do it!
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<a href="https://www.nrmp.org/match-data-analytics/fellowship-data-reports/" target="_blank">Original data here from NRMP</a>. Summary of data for this post below.
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<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjXu0I6I-o9dFd2PyhHBdfBa2Acr8Vjhn4aj0ZshqyxQOLL6cwNUPVNDqnN-yWdRfcGVdBTDfYboXZPo0UHxgNSB77_yBC6APp5C7lSNTnTrpO8ldeodJWKfTnRM7CGf8SjdEO5EyxC99hjqRPwXKIuqcyrA2rjqGazvEm_WQrKdTKdL8TvVDg/s1040/full%20table.png" style="display: block; padding: 1em 0; text-align: center; "><img alt="" border="0" width="600" data-original-height="402" data-original-width="1040" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjXu0I6I-o9dFd2PyhHBdfBa2Acr8Vjhn4aj0ZshqyxQOLL6cwNUPVNDqnN-yWdRfcGVdBTDfYboXZPo0UHxgNSB77_yBC6APp5C7lSNTnTrpO8ldeodJWKfTnRM7CGf8SjdEO5EyxC99hjqRPwXKIuqcyrA2rjqGazvEm_WQrKdTKdL8TvVDg/s400/full%20table.png"/></a></div><br><br>
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For more <a href="https://www.pallimed.org/search/label/sinclair">Pallimed posts by Dr. Sinclair click here.</a><br />
For more <a href="https://www.pallimed.org/search/label/The%20profession">Pallimed posts about the profession click here.</a><br />
For more <a href="https://www.pallimed.org/search/label/fellowship">Pallimed posts about hospice and palliative medince fellowship click here.</a><br />
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<i>Christian Sinclair, MD, FAAHPM is a palliative care physician at the University of Kansas Health System, editor-in-chief of Pallimed, and trying to keep up a resolution to write more about palliative care in 2022.</i>
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Christian Sinclairhttp://www.blogger.com/profile/14685043408496367587noreply@blogger.comtag:blogger.com,1999:blog-13495125.post-56501955789485130922022-05-13T11:00:00.006-05:002022-05-13T11:16:20.924-05:00The Peril and Privilege of Exploration: A Review of Subnautica<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg2rODkb-OEWZ9R0fgqrdt6ih5o-f6Rhv-YV8OGfCGw0cy9mY0R8DkP6GVkdU9cq_OrSF3kG6YDvf0CHSmedeI6BseA01K20VBrLMsE19Q0TzpdnOZypYDUZH8DftSOcQQxjbtGBjcdAmF0XhVFnxGDgktli5wdoR4J-0BLoGojXeLj7Bqxe_4/s1080/subnautica.png" style="display: block; padding: 1em 0; text-align: center; clear: right; float: right;"><img alt="" border="0" width="320" data-original-height="1080" data-original-width="1080" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg2rODkb-OEWZ9R0fgqrdt6ih5o-f6Rhv-YV8OGfCGw0cy9mY0R8DkP6GVkdU9cq_OrSF3kG6YDvf0CHSmedeI6BseA01K20VBrLMsE19Q0TzpdnOZypYDUZH8DftSOcQQxjbtGBjcdAmF0XhVFnxGDgktli5wdoR4J-0BLoGojXeLj7Bqxe_4/s320/subnautica.png"/></a></div>
by Matt Tyler (<a href="https://twitter.com/PalliDad" target="_blank">@PalliDad</a>)
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In the survival game Subnautica, you play the role of a space voyager who has crash landed on an aquatic alien planet. You must find a way to escape while navigating the planet’s beautiful but dangerous flora and fauna. Exploration makes the core of Subnautica, and because I am a palliative care doctor, I couldn’t help but draw a parallel to serious illness conversations. Whether exploring shipwrecks and underwater caverns or the emotions and stories of patients, both require curiosity, methodical skill development, and respect for boundaries.
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Any explorer must first and foremost be curious, even in the face of danger. You won’t make progress in Subnautica if you don’t get close to some scary sea monsters. The same is true for serious illness conversations, maintaining curiosity is essential even when encountering a strong emotion like anger. Rather than presuming an angry patient misunderstands the situation, a curious mind wonders about the origins of that anger and the suffering that may be beneath the surface. The empathy that flows from this curiosity can lead to new levels of understanding.
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And yet, curiosity alone can only take you so far. At the beginning of Subnautica, your basic equipment will only let you explore a short distance below sea level. To discover the planet’s deepest secrets, you must gradually accumulate the resources necessary to upgrade your diving gear. Likewise, we need more than curiosity to explore the complexities of a patient’s physical, emotional, spiritual, social, and cultural needs in the face of serious illness. It takes time to develop the skillset needed to facilitate these conversations, ideally with observation and feedback from experts.
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Even with the most advanced exploration equipment, there are depths in Subnautica that remain out of reach. There are no physical barriers to show that you’ve reached the world’s edge - that understanding only comes with your fully realized abilities. Similarly, seasoned communicators appreciate that although there are parts of a patient’s story that can be explored with advanced skills, there are always boundaries that must be respected. Though it requires a certain level of expertise to see these invisible walls, noticing their presence is vital for creating a patient-centered care plan.
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Ultimately, survival in Subnautica depends not on rebuilding the world to suit your specific needs, but on learning how to work with the world on which you’ve crash landed. Building a relationship with our patients requires the same approach. If we are willing to dive into our patient’s world to understand and support what matters most to them, who knows what beauty can be discovered?
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<i>Subnautica<a href="http://subnauticagame.com/" target="_blank"></a></i> is available to play on PC (Steam), macOS, PlayStation 5, Xbox and Nintendo Switch systems.
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This post has a companion piece video hosted by Digital Doc Games (embedded below). Check out the <a href="https://www.youtube.com/c/DigitalDocGames/featured" target="_blank">Digital Doc Games YouTube channel hosted by Dr. Amiad Fredman</a> for videos on how video games have a huge power to have a positive impact on people's lives.
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<iframe width="560" height="315" src="https://www.youtube.com/embed/YTOKNhKzzpY" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe>
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For more <a href="https://www.pallimed.org/search/label/games">Pallimed posts about games.</a><br />
For more <a href="https://www.pallimed.org/search/label/media">Pallimed posts about culture and media.</a><br />
For more <a href="https://www.pallimed.org/search/label/tyler">Pallimed posts by Dr. Tyler click here.</a>
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<i>Matt Tyler is a palliative care doctor in Chicago. If he's not watching Cocomelon with his daughters, he is probably playing video games.</i>
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<meta name="twitter:url" content="https://www.pallimed.org/2022/05/the-peril-and-privilege-of-exploration.html" />Pallimed Editorhttp://www.blogger.com/profile/11358791266969988517noreply@blogger.comtag:blogger.com,1999:blog-13495125.post-91759599531367275142022-05-02T14:00:00.006-05:002023-06-23T03:49:52.811-05:00Simplifying Opioid Conversions<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgRSO9o_eqbe01Zy4mLju5wFcct39jUa1OOorNI2PSzJnyS8cUja2cgW8Gzniv0ONTlStTVtOR4ObWHW-ScMhq3GZ6dmlPV5U3QpblK92VT75qvhHKO3HDBV_Pit9zvszq1AD3eFwmlbKQbcb4-kaVKGdAvl0j1kXTghhql7QlQN9uXbeEslLE/s1080/Equianalgesic%20Tables%20Are%20Broken%20%283%29.png" style="display: block; padding: 1em 0; text-align: center; clear: right; float: right;"><img alt="" border="0" width="320" data-original-height="1080" data-original-width="1080" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgRSO9o_eqbe01Zy4mLju5wFcct39jUa1OOorNI2PSzJnyS8cUja2cgW8Gzniv0ONTlStTVtOR4ObWHW-ScMhq3GZ6dmlPV5U3QpblK92VT75qvhHKO3HDBV_Pit9zvszq1AD3eFwmlbKQbcb4-kaVKGdAvl0j1kXTghhql7QlQN9uXbeEslLE/s320/Equianalgesic%20Tables%20Are%20Broken%20%283%29.png"/></a></div>
by Drew Rosielle (<a href="https://twitter.com/drosielle" target="_blank">@drosielle</a>)
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A Satirical Monologue in One Act:
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“Ok, 3rd year resident, let’s talk about rotating opioids. What do I mean by ‘rotating’ opioids? It’s just therapeutically switching one opioid with another. It’s um, like, a turnstile, I guess? Anyway--first let’s look at this equianalgesic table. Do you know what equianalgesia means? No? It is the concept that different opioids have the same analgesic power but at different milligram doses due to different potencies. That is, the idea that, say, 50 mg of oral morphine has the same analgesic power as 10 mg of hydromorphone. So 50 mg of oral morphine is equivalent to 10 mg of oral hydromorphone.
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"Ok, let’s look at this table, every entry on this grid is equianalgesic, meaning that the 30 mg here of oral morphine has the same analgesic power as the 1.5 mg of IV hydromorphone. So, let’s say we have a patient on 100 mg oral morphine. How much hydromorphone is that “equivalent” to? Ok, so what we have to do is set up a cross multiplication problem…here’s how you do that.
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[We’ll skip the painful talk-through of the cross multiplication.]
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"Ok, so it looks like the answer is 5 mg of hydromorphone IV. Now we have to adjust that dose for incomplete cross-tolerance. Do you know what that is? No? Ok, so incomplete-cross tolerance is the idea that our patient on 100 mg of morphine is somewhat tolerant to the morphine. They are therefore also presumably somewhat tolerant to any other opioid agonist like hydromorphone. The problem is that the tolerance they have to morphine may not fully apply to the tolerance they have to the hydromorphone—the morphine tolerance “incompletely” transfers so to speak to the patient’s hydromorphone tolerance. So, what that means is that even though this table says 100 mg of PO morphine is equal to 5 mg IV hydromorphone, for safety’s sake we need to reduce that 5 mg somewhat to determine what we <i>actually</i> put the patient on. That’s what we mean by reducing for incomplete cross-tolerance.
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"If you have 5 minutes, it’s actually an interesting story, because no one is really sure that ‘incomplete cross-tolerance’ is even physiologically a phenomenon, like on the cellular level, our field just calls it that because that’s what it’s always been called. In fact, the idea of ‘incomplete cross-tolerance’ only makes sense if you think there actually is a firm “equianaglesic” potency relationship between morphine and hydromorphone that applies to most patients. In fact, no one actually believes that and the broad consensus is that there is a pretty significant range of ‘equianalgesia’ between any 2 opioids in different patients. I.e., in one patient, 100 mg of oral morphine may end up providing equal analgesia to 12 mg IV hydromorphone, in another patient, 4 mg of IV hydromorphone, etc. It’s a little bit of a crap-shoot.
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"Actually, it’s probably far worse even with fentanyl, we’re talking about a far, <i>far</i> wider range of individual responses, and don’t even get me started talking about methadone and buprenorphine [self-knowing chuckle here]!
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"So, back to incomplete cross-tolerance. If you’re going to argue that it would just be easier to say ‘dose reductions due to safety’ or ‘dose reductions due to individual variability in responding to opioids’, you’d be right. That’s much easier to understand, and probably more accurate, but maybe it makes us feel like we’re the keepers on secret knowledge to say incomplete cross-tolerance? Who knows?
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"Regardless, this is where it gets really interesting, because to properly account for ‘incomplete cross-tolerance’ we have to decide how much less opioid we need to put someone on after we do the initial calculation. Yes, there are 2 calculations: the equianalgesic one, then a 2nd incomplete cross-tolerance one in which we reduce the first amount by a further amount, most people recommend 25-50%.
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"How do you choose how much you actually dose reduce? Well, there’s about 10 patient factors you need to balance when making that decision. Yes, I said 10, but don’t worry, if you do this for a couple years it’ll become second nature to you [self-knowing chuckle]!
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"Ok, so let’s talk about these 10 patient factors….”
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[End]
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Dear friends and colleagues, I think we can all do better than this, and here is my current thinking as to a better approach.
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In my <a href="https://www.pallimed.org/2022/03/opioid-equianalgesic-tables-are-broken.html" target="_blank">last post I outlined why I think equianalgesic tables (EATs) are broken</a> and proposed we collectively move instead to using Conversion Tables (CTs) when teaching others how to switch opioids. Briefly, this is because CTs engender much simpler and clearer math; and we can easily adjust the conversion factors in CTs based on emerging data, without having to rejigger every ‘equianalgesic’ relationship which EATs force us to do. My offer from the last blog post still stands: it would be ideal if there could be a consensus process to generate a consensus CT that our professional community can broadly adopt. While I like the CT I made, I don’t think any one person should be setting the conversion ratios alone, even if it is standing on the shoulders of giants! I’m not an investigator but am willing to lend any support I can to this. It is also possible the best option is for organized medicine to lead this, and I’ve been chatting with some folks about this a little already. I’m not sure where it will lead, nor if AAHPM has any appetite for that, we’ll see.
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Regardless, I’ve been thinking and talking with others a lot about the entire enterprise of how we teach and talk about opioid switching and I have a lot of ideas that go beyond CTs for potential ways we can improve our approach to this. This post is simply to capture those ideas, none of which I’m claiming are independently mine.
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<b>1) We should never utter the phrase “incomplete cross-tolerance” again. </b>
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I hope this is not controversial, I’ve yet to meet anyone in the “Incomplete Cross-Tolerance: What a Super Helpful Concept!” camp, but its use continues to pervade discussions of opioid switching. My fundamental objections to incomplete cross-tolerance: it is a concept that requires an entire paragraph of explanation (!!) to someone unfamiliar with it, plus it may not even be a ‘real’ thing, plus there are readily available, broadly understood, completely accurate alternatives to it (e.g., dose reductions for safety, dose reductions due to individual variability, etc.). While the monologue that started this post is satire, I’m sure I’ve uttered every phrase in it for real at one point or the other in the past 20 years. I know I am not alone.<br><br>
<b>2) We should talk about ‘methods for safe opioid switching’ and not equianalgesia. Equianalgesia is unnecessarily jargony and I don’t think it even exists on the population level.</b>
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Incomplete cross-tolerance only makes sense if we think equianalgesia itself is a firm and helpful concept. If you believe that we can announce, without qualification, that 20 mg of IV hydromorphone is ‘equianalgesic’ to 100 mg of oral morphine then maybe it makes sense to talk about incomplete cross-tolerance. But I don’t know of anyone who thinks that “100 mg of oral morphine is equivalent to 20 mg of IV hydromorphone” in any sort of widely generalizable, arbitrary way. I think all of us operating in this realm may acknowledge that across 100 patients maybe the averages end up close to 100:20, but who cares? Honestly, that factoid is a DISTRACTION because the way EAT switching has currently been set up has encouraged us to first focus on this fake-and-based-in-less-science-than-we’d-want notion of equianalgesia, then prompted us to do this secondary work-around-caused-only-by-the-fact-that-we-set-a-ratio-in-the-first place. <i>Why do it this way?</i> Why not just switch at a ratio that works most of the time, instead of nearly none of the time?
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The clinical task we are faced with is not an abstract exercise in the variable potencies of different opioid molecules averaged across the human population, instead it’s a practical task of <i>How do I safely switch this patient’s opioids?<b></b></i> Safely means two things here: that the patient does not have significant sedation from the switch nor a major worsening of their pain. I do think what I’m arguing here is more than semantics—that going from equianalgesia to ‘methods of safe switching’ is not just me renaming it. It is a significant conceptual frame shift in this critical and common.
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Using a concept like ‘equianalgesia’ promotes this idea that there’s a “right answer” to the question of “If I’m switching someone from 100 mg of morphine in a day to IV hydromorphone how much hydromorphone do I prescribe?”
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My proposal is there isn’t a right answer. It is not a helpful goal or concept and we need to move onto the more salient task of <i>switching safely</i>. That framework focuses us on a <i>practical clinical task</i>. From talking to colleagues, many of us who prescribe methadone and buprenorphine long ago moved on from any idea that it was our task to somehow divine the ‘equianalgesic’ dose of methadone from another opioid. Instead, we have a protocol to make the switch, the protocol works (‘is safe’), all is well with the world. My proposal here is that this is how we conceptualize all opioid conversions.
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<b>3) We must start emphasizing that the absolute dose of opioids involved matters for safe switching.</b>
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Stepping back from the finer points of what conversion ratios we should be using for opioids—honestly, if what you’re talking about is doses in the range, say, of 40 mg of oral morphine, I don’t really think it matters what ratios you use to switch. Frankly, it probably doesn’t matter much if you reduce further for safety or not. <br><br>
Consider someone is on 40 mg a day of morphine PO. You want to put them on IV hydromorphone:<br><br>
-- Classic EAT: divide by 20 to get 2 mg of IV hydromorphone<br><br>
-- DOC2 Table: divide by 12.5 to get 3.2 mg of IV hydromorphone<br><br>
If you reduce further for safety, presumably you’ll still get an answer about 1.2 mg apart between the 2 tables. Honestly, I don’t think the difference there is much of a safety concern. Both are fine. No opioid- tolerant patient became sedated or had a pain crisis because of a difference of 1.2 mg of IV hydromorphone over 24 hours; of course, the ‘fine-tuning’ might be a bit different, but as long as a patient had close follow-up the analgesic outcomes would be about the same too.
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But what if the patient was on 400 mg a day of oral morphine? Personally, I would not be so cavalier about saying there is no relevant difference between 20 and 32 mg of IV hydromorphone in a day.
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Yet, if you read pretty much all the opioid conversion stuff out there, they all treat these opioid switching ratios as <i>fixed across all ranges of opioid doses</i>. They suggest the same approach for 400 mg of morphine as 40 mg of morphine. To me, this is shocking, and profoundly unsafe. I’ve never met a single person who treats opioid switching ratios as linear across all opioid doses, meaning they would be more ‘conservative’ in their switching for someone going from 400 mg of morphine than 40 mg. I believe I am merely naming here a clinical practice which is already widespread! Yet, for the last twenty years of journal articles, books, national presentations, and local presentations that I’m aware of, this is not splattered in flashing neon ALL CAPS at the top of every table. It is not a core part of our basic nor specialty teaching on this topic. I genuinely don’t understand it.
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Fundamentally, I’m arguing that we’ve heaped HUGE amounts of attention on the complex subtleties and nuances of reducing for safety when it comes to opioid switching, and virtually no attention to the nuances of switching at higher dose ranges. I think we got this wrong.
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All this leads me to a few practical proposals:
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<b>1) “We”* stop using EATs and instead use simple “going from X to Y” conversion tables </b>(<a href="https://www.pallimed.org/2022/03/opioid-equianalgesic-tables-are-broken.html" target="_blank">see this post for more details</a>).
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<b>2) We frame this practice as methods of ‘safe switching’ and do away with ‘equianalgesia’ (at least as a core concept in teaching others about opioid switching) and ‘incomplete cross-tolerance’ (that we can discard completely).</b>
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<b>3) We promulgate a conversion table without need for additional dose reductions in most patient scenarios.</b> I appreciate this is in some ways the most radical thing I’m proposing here, and certainly it is the one I’m most tentative about. But I suspect that a lot of our need for “reducing for incomplete cross-tolerance” has come from the fact that in order for any of our EATs to make sense they’ve needed to have on them conversion ratios that are dangerously aggressive. E.g., the for the Classic EAT I would divide the PO morphine dose by 20 to get the IV hydromorphone dose and, truth be told, it would be rare I would dose reduce beyond that: it was a good safe ratio much of the time in my experience. However, the reverse conversion, multiplying the IV hydromorphone dose by 20 to get the PO morphine dose, I regularly, heavily dose reduced (often by 50%). My argument is that to a large extent our need to create that 2nd step of dose-reduction really comes from the fact that we locked ourselves into aggressive conversion ratios with EATs and if we had just a simple “Going from X to Y” conversion table with pre-set ‘safe’/conversative ratios, we can side step this incredibly complex beast we’ve created (the need to reduce for safety / “incomplete cross tolerance”). <br><br>
How would we do this: my idea is that we create a conversion table which folks broadly agree they’d be comfortable handing to a first month medical intern and telling them: “Young doctor, within these parameters, just use this.” If this idea freaks you out, remember for decades we’ve handed them <i>inscrutable</i> equianalgesic tables with even <i>more inscrutable and hand-waving</i> suggestions about reducing for incomplete cross-tolerance and expected them to know what to do. My hypothesis here is that the method I’m proposing is safer and requires far less needless work for our generalist colleagues.
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As an example, we’d create a conversion table for a hypothetical 70-year-old with an eGFR of 50 and mild frailty—something like that. The idea being that most of the conversions happening out there are for patients like that or more physiologically robust, so the table would be built-in safety for a broad range of patients. I think it could be close to my draft Conversion table (<a href="https://www.dropbox.com/s/ewrftph3d48d0k0/When%20going%20from___opioid%20conversion%20Mar2%202022.pdf?dl=0" target="_blank">Dropbox</a>, <a href="https://drive.google.com/file/d/1otYvy_JbMIXyF4ixo_j0WIaMqiV08hZ2/view" target="_blank">Google Drive</a>), but some of the conversions would be more conservative for sure.
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The table would need to be explicitly labeled with the dose limits (E.g., this is for patients on 100 mg or less a day of oral morphine, 20 mg a day or less of IV hydromorphone, etc. This would avoid unnecessary calculations of oral morphine equivalents (OMED, OMDD, OMD, or any variation on those abbreviations). What those ‘dose caps’ are would require, I imagine, vigorous discussion, and I don’t strongly believe the, e.g., 100 mg a day morphine cap is actually the right one.
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The table and associated teaching strongly emphasize the structure of care and close follow up is what’s most important for switching opioids safely. Don’t switch and walk away, switch and follow up!
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Importantly, I’m proposing this is a conversion table for ‘generalists’ who switch opioids. I think the role of palliative and pain specialists is to have a deep knowledge of all this, including the history of opioid switching, and the nuances of dose reductions for safety, etc. All our fellows (and all our colleagues) should read <a href="https://store.ashp.org/Default.aspx?TabID=251&productId=212130737" target="_blank">Demystifying Opioid Conversions 2 Ed (aka DOC2)</a> if they haven’t already! However, that book is not for generalists, they aren’t reading it and we can’t expect them to read it. To be clear—I’m not suggesting we jettison that book or the accumulated knowledge of opioids switching, I’m more proposing there are simpler and arguably a little safer way to teach our generalist colleagues about this, keeping in mind that to date we’ve made it so difficult for them most of them are using online calculators of various levels of reliability!
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This is just a proposal which has come out of one person’s brain. I very much believe that ideally this is best decided by consensus and committee (in the absence of good clinical data for which there are zero). So, it is meant as a starting point for discussion. Ideally, I’m hoping others will join me and I am talking with CAPC about this and plan on with AAHPM too. I think the new data from MD Anderson which lead to the change in the DOC2 Table are a great opportunity for us as a field to collectively look at all this and try to do something that is far simpler, and at least a little safer. If you’re interested, let me know!
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(This post was updated May 3, 2022 to correct an error in the opioid calculations!)
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For more <a href="https://www.pallimed.org/search/label/opioids">Pallimed posts about opioids.</a><br />
For more <a href="https://www.pallimed.org/search/label/rosille">Pallimed posts by Dr. Rosielle click here.</a>
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<i>Drew Rosielle, MD is a palliative care physician at the University of Minnesota M Health Fairview in Minneapolis. He founded Pallimed in 2005. You can occasionally find him on Twitter at <a href="https://twitter.com/drosielle" target="_blank">@drosielle</a>.</i>
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<meta name="twitter:url" content="https://www.pallimed.org/2022/05/simplifying-opioid-conversions.html" />Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.comtag:blogger.com,1999:blog-13495125.post-88307624273843814512022-03-21T13:42:00.007-05:002023-06-23T03:48:45.439-05:00Opioid Equianalgesic Tables are Broken<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEiDy_uWN7-5CoNvDxSKx3qtmdnBC8cX3UJ4GP8s6jkybQG5WKZoZNZcTfablFZgDe3nn4Ig7gShLyjQBzfN-XdosUEcGnJnENZnJz3R9K-WJSrRNmmI_MXxJrA9twNHG96lFkC0Yujij2ZyadnfSGGXWgG1DAktBJqgFR_J1dlnKXilcJXhsMo=s1080" style="display: block; padding: 1em 0; text-align: center; clear: right; float: right;"><img alt="" border="0" width="320" data-original-height="1080" data-original-width="1080" src="https://blogger.googleusercontent.com/img/a/AVvXsEiDy_uWN7-5CoNvDxSKx3qtmdnBC8cX3UJ4GP8s6jkybQG5WKZoZNZcTfablFZgDe3nn4Ig7gShLyjQBzfN-XdosUEcGnJnENZnJz3R9K-WJSrRNmmI_MXxJrA9twNHG96lFkC0Yujij2ZyadnfSGGXWgG1DAktBJqgFR_J1dlnKXilcJXhsMo=s320"/></a></div>
by Drew Rosielle (<a href="https://twitter.com/drosielle" target="_blank">@drosielle</a>)
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I am proposing we do away with equianalgesic table (EAT) as a tool to inform clinical decisions about opioid rotations/conversions. Fundamentally, EATs create too many problems, and there are simpler and safer ways to teach clinicians how to convert between different opioids.
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<b>Part 1: New Data Can't Fix the EAT </b>
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A couple HPM fellows every year ask me which table do I prefer to use—the old EAT or the new one? By the old one, they refer to the table most of us used or were at least deeply familiar with for the last 10-20 years. By the new one, they mean the one created by Dr. Mary Lynn McPherson, PharmD in her <a href="https://store.ashp.org/Default.aspx?TabID=251&productId=212130737" target="_blank">landmark book <i>Demystifying Opioid Conversions</i>, 2nd Ed</a>. If you haven’t read the book, please do, it’s really one of the best things ever written about opioid conversions. My disagreement with the book, which is admittedly a big one, is that the book promulgates the use of EATs, and my entire argument today is really in some ways inspired by the conversations I’ve had with my fellows and others as we grapple with the new EAT in her book. (From here, I’ll refer to the tables as ‘Classic’ and ‘DOC2’.)
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Fundamentally, my argument is EATs themselves are intrinsically flawed: they ‘force errors’ in a way that’s entirely unnecessary and avoidable if one just doesn’t use EATs as clinical decision aides (I’ll elaborate on that statement below). Dr. McPherson’s curating and teaching new, reliable clinical data is critically important, yet better data in a flawed model like the EAT creates as many problems as it solves. I feel a little awkward putting all this out like this. Dr. McPherson is one of my heroes. The DOC2 EAT crystallized concerns I’d had over the years, and the followinghas come from conversations about EATs prompted by me and my colleagues grappling with a new table. The new DOC2 EAT is clearly better in important ways, but I also think recapitulates all the problems intrinsic to EATs, so much so we collectively should consider doing away with them.
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The 2010 table is the Classic EAT, the 2018 table is the DOC2 EAT. You can see it’s changed throughout, but the big changes are the around hydromorphone, with the biggest changechanging the20:1 PO morphine:IV hydromorphone ratio to a 12.5:1 ratio.
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The big changes in the DOC2 EAT are based on <a href="https://pubmed.ncbi.nlm.nih.gov/28711751/" target="_blank">this study by Dr. Akhila Reddy and colleagues looking at real life data about converting hospitalized cancer patients from IV hydromorphone to PO morphine, PO hydromorphone, or PO oxycodone</a>. Reddy et al found that the average IV HM to other drug ratios were 1:2.5 for oral hydromorphone, 1:11 for oral morphine, and 1:8 for oral oxycodone (meaning in this population, a patient on 10 mg/24 hours of IV HM, on average would end up on 25 mg PO HM / 110 mg PO MS / 80 mg PO oxycodone per 24 hours). Importantly these doses are lower than what the Classic EAT would predict, and for PO morphine and hydromorphone, <i>a lot lower </i>(Classic EAT promotes a 1:5 ratio for IV HM:PO HM; 1:20 ratio for IV HM:PO MS; and 1:10 ratio for IV HM:PO oxycodone)!
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To the best of my knowledge, the DOC2 EAT exists largely to better account for these ratios going from IV hydromorphone, considering that Reddy et al is undoubtedly the best/biggest real-patient study looking at this very relevant real-life clinical question. (It also tweaked the IV to PO morphine ratio in a small manner, going from 1:3 to 1:2.5. Probably small enough not to matter for patient care, but enough to make for more challenging math, but that is a small quibble).
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I want to observe that I think the Reddy et al study is <i><b>a landmark study</b></i>, and I think it provides the best evidence we have of ‘real-world’ “equianalgesia” when going from IV HM to those other opioids. I absolutely think we should all be modeling our clinical practice of opioid conversions on these data as best we can!
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The problem is, however, when you try to ‘map’ these data onto the rigidity of an EAT, in which every ‘relationship’ between opioid doses/routes is fixed and bidirectional, you encounter all sorts of problems, ALL OF WHICH exist due to fact that you are using an equianalgesic table in the first place. What I mean is that all the problems that are introduced by creating a new EAT from this study, merely exist because we, as a professional community, have decided that EATs are the best format for presenting information to guide opioid conversions. The fixed and bidirectional nature of EATs itself creates the problem, and my argument is that all this will go away if we discarded EATs entirely as teaching tools/clinical decision aides for opioid switching.
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Let’s look at the IV HM to PO MS ratio in the EATs as an example. In the Classic EAT there is a 1:20 (look at the table: 1.5:30 is a 1:20 ratio). Meaning you’d convert 1 mg of IV hydromorphone to 20 mg of PO morphine, and you’d convert 20 mg of PO morphine to 1 mg of IV HM (before dose-adjusting due to ‘incomplete cross tolerance, patient factors, safety, etc).
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Reddy et al gave us good reason to believe that when converting from IV HM to PO MS, that 1:20 is <i>too aggressive</i>: the morphine dose is too high. So, if you change the EAT from 1:20 to 1:12.5 which is what the DOC2 EAT recommends, you get a conversion that’s more in line with current knowledge.
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So far, so good! <i>But, now look at what happens when you use the tables to convert from PO MS to IV HM</i>. 100 mg PO morphine in 24 h converts to 5 mg IV HM in 24 h using the Classic EAT ratio of 20. Using the DOC2 EAT ratio of 12.5 you get 8 mg of IV hydromorphone. We’ve all of a sudden made the conversion in the reverse direction far more aggressive than it previously was with the Classic EAT! Is there any data to support being far more aggressive in this direction? No, not that I know of; the data are only about <i>going from </i>IV HM to other opioids, not <i>to</i> IV HM.
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So, in making a conversion more conservative/more evidence based in one direction, we’ve made it substantially more aggressive in the opposite direction, and done so without any evidence backing it up.
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The same thing happens with IV to PO HM. Reddy et al suggests IV HM going to PO HM is a 1:2.5 ratio which is reflected in the DOC2 EAT (Classic EAT has a 1:5 ratio). However, that makes a user of that table use twice the amount of IV HM when going from PO HM than the Classic EAT suggests. This <i>doubling-of-how-aggressive-we-should-b</i>e with that conversion, as far as I can tell, is not based on any data, and I argue it’s no small thing to put out a EAT which encourages doubling the dose of IV hydromorphone compared to prior practice without safety data, but it’s an unavoidable byproduct of the Reddy data <i>being forced into the format of an EAT.</i>
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My point here is that using an EAT forces us to do this. There is no way around this in the format of an EAT: the<i> fixed bidirectionality of EATs causes this</i>.<b> So—why do we even use EATs?</b>
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The best data we have about going from IV HM to PO oxycodone is that it’s a 1:8 ratio. However, the new DOC2 EAT uses the Classic EAT 1:10 ratio. Why? I’m assuming it’s an effort to keep the DOC2 EAT coherent. Think about what it would look like if you used a 1:8 ratio. In the DOC2 EAT, 2 mg of IV HM would map to 16 mg of PO oxycodone. But that means that 16 mg PO oxycodone would map to 25 mg of PO morphine! What a bleeding mess!
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And that’s the point: EATs exist in some sort of fantasy universe in which we have for some reason assumed, based as far as I can tell, on no data whatsoever, that the RATIO of morphine to hydromorphone, has to exist in a fixed and eternal relationship with the relationship between, say, oxycodone and hydromorphone. Based on EATs, if you tweak the relationship between oxycodone and hydromorphone it impacts the potency relationship between morphine and oxycodone! They all are forced to shift together because the whole idea behind an EAT is that every value in every cell of that table is ‘equianalgesic’ with the other values.
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Why? I don’t see any data to think this has to be the case, at all. All of this strikes me as an overly simplistic and rationalistic assumption of how incredibly complex things work, that creates all of these issues I’ve been elaborating above when you try to do the right thing, which is what Dr McPherson did when she updated her EAT based on good data! The problem is that the format of the EAT itself undermines any effort to use better data to improve it.
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<i>Dear colleagues, we don’t have to keep doing this to ourselves. There is another way, some of you are probably already using different methods anyway, and I’ll propose one in a bit, but first I want to make one more argument against EATs in general: they force people into doing unnecessarily complex math.</i>
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<b>Part 2: Complex Math is Complex</b>
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EATs encourage people to do unnecessarily complicated math. I’m sure I’m not the only greying palliative clinician who’s realized the last several years that a large number of the fellows and residents I work with don’t actually know how to use an EAT. They instead use opioid conversion smartphone apps or websites. Years ago they didn’t know how to use EATs either for the most part, what’s changed now is that they can avoidlearning how to use them completely due to the software converters. (By the way, every single app/website I’ve looked at base their math on EATs and so have in them all the fixed bidirectional problems I mentioned above).
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A few months into the fellowship year when I’m working with fellows and one is using an app I’ll ask them to walk me through an opioid conversion calculation. It’s not uncommon for me to realize that they just can’t do it. These are physicians, these are people who are highly educated and know their way around algebra, but they still avoid doing EAT math because it’s clunky, it’s easily confusing, and legitimately easy to make mistakes.
This is because they are taught that the way you use EATs to calculate the dose of the new opioid is this:
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Holy smokes we make them do cross multiplication!
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I’ve learned that cross multiplication makes some people really uncomfortable. And frankly I don’t blame them—it’s easymake mistakes— it’sto multiply when you should divide, etc. I myself, long before my current thoughts about wanting to discard the clinical application of EATs began to solidify, had just completely stopped using cross multiplication in doing these conversions over a decade ago. I have always looked at the table, calculated a conversion factor, and just used that.
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For example, looking at the Classic EAT, it suggests 1.5 mg IV hydromorphone is ‘equipotent’ to 30 mg PO MS. That’s a conversion factor of 20: 1.5 x 20 = 30, right? So if a patient was on 10 mg of IV hydromorphone, I’d just multiply that by 20 to get 200 mg of PO morphine, and go from there (adjust the dose down for patient safety reasons etc). I would’t bother doing cross multiplication at all.
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This math is much easier to my brain, and also easier to ‘gut check double check’ your math, because you ‘know’ a morphine dose is 20 times the HM dose. With cross-multiplication, those relationships are less obvious, and so easy to invert, especially for novice users, who don’t have an intuitive sense for instance if PO hydromorphone is more or less potent than, say, IV morphine!
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Making people to cross-multiplication was a huge pedagogical error. Thankfully, it’s totally unnecessary.
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<b>Part 3: Conversion Tables as a Better Tool (?)</b>
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All this adds up to my modest proposal: that we do away with EATs entirely as we teach others how to convert between opioids, and replace them with Conversion Tables, that aren’t really tables, just a condensed clinical decision aide in prompting clinicians with easy math and individualized, conservative conversion recommendations that are specific to each conversion. For instance, the conversion tip for going from IV hydromorphone to PO morphine exists independently of the conversion tip for any other conversion including even a different ratio for converting from PO morphine to IV hydromorphone.
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I want to acknowledge that I did not invent this idea. I’ll be honest, I’m not sure where in the depths of my memory it came from, but in some ways it’s such an obvious idea I hope when I post this people will comment with examples of opioid rotation decision tools which use the conversion factor approach instead of an EAT! I’m sure it’s out there. If anything is novel about what I’m writing today, it’s mostly in the call to broadly give up on the EAT as a clinical decision tools, not the novelty of using conversion factor tables.
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From all this, I’ve mocked up a Conversion Table (pics below of an abbreviated pocket card sized Table and part of the full, annotated Table, with all my explanations and anxious thoughts about the factors, and links to more detailed (<b>but not ready for clinical implementation-see below<i></i></b>) versions: <a href="https://www.dropbox.com/s/ewrftph3d48d0k0/When%20going%20from___opioid%20conversion%20Mar2%202022.pdf?dl=0" target="_blank">Dropbox</a>, <a href="https://drive.google.com/file/d/1otYvy_JbMIXyF4ixo_j0WIaMqiV08hZ2/view" target="_blank">Google Drive</a>).
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This is one section of the longer, annotated Table:
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<b>Benefits and Caveats of Conversion Tables:</b>
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• Every single conversion can have its own ratio, and that ratio can evolve/change over time (due to new data or clinical wisdom) easily, without messing up any of the other conversions. You can change the IV HM to PO morphine conversion without that having ripple effects on every other conversion!<br>
• Along those lines, we can have different ratios going from, e.g., IV HM to PO morphine than when we go from PO morphine to IV HM. My argument is that a key reason to do it this way is safety, mainly because if we as a professional community tighten up one conversion it doesn’t force us to ‘liberalize’ its reverse.<br>
• It prompts easier math. Every conversion is just one multiplication or division problem.<br>
• This is true in my opinion of all opioid conversions, regardless of which table you are using: we should increasingly become more and more cautious in all opioid conversions the higher the doses that are involved. I personally think all conversion tables and EATs should have a huge warning on them that says something like “DO NOT USE THESE RATIOS FOR OPIOID DOSES HIGHER THAN 150 MG OF ORAL MORPHINE EQUIVALENTS—CONSULT AN EXPERT” or something like that. (Feel free to argue with me about the 150 mg figure—I don’t myself know what the limit should be other than that number is something that feels good in my gut but that’s all.) <a href="https://www.pallimed.org/2019/10/part-4-everything-we-were-taught-about.html" target="_blank">I wrote about this in detail in 2019</a>. The bottom line is that I think we should treat all opioid conversion ratios as non-linear at high doses, like we do with methadone at all doses, and that every single guide to opioid conversions needs to SCREAM this.<br>
• Along those lines, I can imagine someone saying about all this, “Look, does it really matter which table we use because, let’s say we’re going from PO to IV hydromorphone, does it really matter if the final answer is 2 or 4 mg!” I would say I am highly sympathetic to that perspective. Look, the reality is, at lower doses, for the vast majority of our patients, it honestly doesn’t make that much of a difference! But, my argument is, the higher the doses involved, the more this stuff really starts making a difference. I am NOT going to lose sleep over if my fellow puts a patient on 2 vs 4 mg of IV hydromorphone a day. I am going to lose sleep over 20 vs 40 mg of IV hydromorphone a day though! This is why 1) I think whatever we put out there for the non-specialist clinician to use needs to be conservative because clinicians will use these at high doses if we put them out there, and 2) we need to signal/emphasize/warn on EATs or Conversion Tables that they are not to be applied at those higher doses! Honestly, I think that’s an even more critical safety practice than fine-tuning the actual conversion ratios.<br>
• Please look through the draft/mock ups of the conversion tables. <b>I don’t mean these to be implemented in clinical settings currently!!<i></i></b> I have spent more time arguing with myself about the actual numbers (conversion factors) I put down on paper in those tables than I have writing this cruelly long blog post (you can see some of my comments about my decisions in the Annotated Tables—I’ll let you know that at one point these included conversions around IV fentanyl and I just gave up it’s such a mess). Part of the debate I have with myself is, from a pedagogical standpoint, just how conservative should these numbers be? Should we automatically make them so conservative that we can say that for the ‘average patient’ you don’t need to dose-reduce further? Should we still even be incorporating ideas of incomplete cross tolerance, which, I probably don’t need to tell you, is an incredibly complex, and nuanced thing we inflict upon others. I.e., we show people these tables, tell them to use them, then say, "Oh by the way once you’ve done that you need to make a highly complicated, patient-specific decision about manipulating the final dose ever further, based on these TEN DIFFERENT FACTORS!" I do wonder if we can do better than that.<br>
• I’m not sure what the right answer is here. Certainly, I’m not the one to be deciding this, either! My dream would be that something like this is workshopped and researched with clinical and pedagogical leaders then tested in some way for safety, and I think the ‘best answers’ as to how conservative these numbers should be would come out of that dream process. What I’ve mocked up are things I’d feel comfortable handing a fellow personally, but I just want to be clear to the world I am not proposing my draft tables as anything more than an example of what a hypothetical conversion table could look like in the future. That’s it.
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I’m very curious what people think about this. Who’s already moved away from EATs to conversion tables or something similar? What do people think of my draft Tables? I am not an investigator, but if someone who is, and knows how to lead an investigation into validating something like this (not that EATs themselves were ever validated), please ping me. I’d love to chat. I smell a Delphi study!
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Post-script, because I sure someone is going to bring this up, and rightfully so: I’m not arguing that we entirely discard EATs for every single application out there, just the clinical/pedagogical ones. They arguably have a role in research and public health—e.g., the ideas in EATs give us a way to calculate OMEs/MEDDs (24 h oral morphine equivalent dose). I think the idea of the OME has its utility at least in research contexts, and we need some way to calculate it, and sure an EAT is an ok way to do that, although I’ll also point out that the OME has been weaponized in the last several years by those who insist, for example, that an OME of 50 mg is some sort of evidence-based hard limit on safe opioid dosing, and the insidious carceral/cops-in-medicine ‘tool’ that is the NarxCare Score. <br><br>
For more <a href="https://www.pallimed.org/search/label/opioids">Pallimed posts about opioids.</a><br />
For more <a href="https://www.pallimed.org/search/label/rosielle">Pallimed posts by Dr. Rosielle click here.</a>
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<i>Drew Rosielle, MD is a palliative care physician at the University of Minnesota & M Health Fairview in Minneapolis. He founded Pallimed in 2005. You can occasionally find him on Twitter at <a href="https://twitter.com/drosielle" target="_blank">@drosielle</a>.</i>
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<br><br>Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.comtag:blogger.com,1999:blog-13495125.post-61081262949699548382022-01-24T16:45:00.003-06:002022-01-24T16:53:44.822-06:00The Annual Assembly and COVID<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEhwePFUk4VxA6jlhDBShMIUlF0nEPiqDfpBxjAL79areaYeXh3hXaOPt272utE62WEuilqjwkrNVb5diqkPHMgWSkJivLfSanLLTUuyWeTZRXPfCum2LWgKipgph4XyDugYh8Ub8tUdNCiyMa3FesJXz2LpYG6efkmT_kzaZzFgT7XkaDYYjaU=s800" style="display: block; padding: 1em 0; text-align: center; clear: right; float: right;"><img alt="" border="0" width="320" data-original-height="800" data-original-width="800" src="https://blogger.googleusercontent.com/img/a/AVvXsEhwePFUk4VxA6jlhDBShMIUlF0nEPiqDfpBxjAL79areaYeXh3hXaOPt272utE62WEuilqjwkrNVb5diqkPHMgWSkJivLfSanLLTUuyWeTZRXPfCum2LWgKipgph4XyDugYh8Ub8tUdNCiyMa3FesJXz2LpYG6efkmT_kzaZzFgT7XkaDYYjaU=s320"/></a></div>
by Christian Sinclair (<a href="https://twitter.com/ctsinclair" target="_blank">@ctsinclair</a>)
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Last week, many hospice and palliative care clinicians and advocates received the unfortunate news that the 2022 Annual Assembly of Hospice and Palliative Care (#hapc22) was moving from hybrid (both in person and virtual) to virtual only. The board of directors of AAHPM and HPNA "considered the current strain on health care systems, personnel and their families" when making the decision. And then one week later, many presenters found out their presentations were not going to be in the virtual-only assembly. That is immensely disappointing. I received notice that my talks - on which colleagues and I had spent hours working - were canceled too. I was shocked at first, then mad, a little incredulous, then sad I would not get to share my work with a wider audience. Online, others shared similar emotions about the bad news. It really stinks.
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I think it is critical to direct the majority of ire at COVID, which threw us all a curve ball with omicron. Honestly going into October and November, many clinicians I know were beginning to regain that hope and return to normal. The clinic visits were more often in-person (rather than telehealth). We had meetings with small groups in big rooms. All signs pointed to "Yes!" An in-person Annual Assembly in Feb 2022 seemed possible. So when you feel angry, make sure to direct that anger at COVID..
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As for mitigation of risk, or different strategies, or communication planning around this issue, it is reasonable to ask for more information from the two organizations, but let's make sure we are asking the right questions and the right people. The strategy is the responsibility of the board of an organization. The staff of an organization is responsible for executing on the plan set out by the board. Boards need to make very difficult decisions. From personal experience, those conversations before the decision can also be quite challenging. I think the business meetings for both HPNA and AAHPM should be high on your priority list if you want to hear more about how we got here. If you want more information or have issues with how things were handled, reach out to board members to tell them what is important to you.
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One thing to keep in mind is that leadership is likely feeling some of the same emotions we are feeling. I know this from personally working with the AAHPM and HPNA staff. They put a lot of time and effort into making the 2022 Annual Assembly happen, and now a lot of that work is lost. So when reaching out to them for clarification or giving feedback, make sure to appreciate the ripple effects of COVID and that many of these decisions are often more difficult than they appear on the surface.
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And if you still don't like how leaders are making decisions, then consider running for a volunteer position. Influence in a way that you think is best. There are always volunteer roles to fill. And it offers a perspective that things are often more difficult than they appear on the surface.
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And lastly,I'm sorry that your work and the work of your colleagues and mentees won't get the attention of a national meeting. And yet, the good work is done. It just needs a little extra effort to find a home. Like one of my favorite quotes from Austin Kleon, "Do good work, and put it where people can see it." Already online, there are venues like <a href="https://twitter.com/HAPCVrtDidactic" target="_blank">HAPC Virtual Didactics</a>, <a href="https://twitter.com/FridayChalkTalk" target="_blank">Friday Chalk Talk</a>, GeriPal, and even Pallimed, making themselves available to repurpose or rework content. Honestly, this is something I would love to see our field do more of. Don't stop at "Well, I presented at the Annual Assembly. My work is done here." Call up colleagues at other institutions and let them know you have an excellent presentation for their next grand rounds. Do a media tour for the field: pitch your content to your local news media or write an editorial for national outlets like NYT, WaPo, The Atlantic, etc. Write a paper and publish it in an academic journal. Some of this you can do all on your own, some of it may require activating your mentor and peer network. So yes, feel your feelings, and then get to work finding a home for your great work. All is not lost.
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For more <a href="https://www.pallimed.org/search/label/aahpm">Pallimed posts about AAHPM.</a><br />
For more <a href="https://www.pallimed.org/search/label/hpna">Pallimed posts about conferences.</a><br />
For more <a href="https://www.pallimed.org/search/label/Sinclair">Pallimed posts by Dr. Sinclair click here.</a>
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<i>Christian Sinclair, MD, FAAHPM is a palliative care physician at the University of Kansas Health System, editor-in-chief of Pallimed,and trying to keep up a resolution to write more about palliative care in 2022.</i>
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Christian Sinclairhttp://www.blogger.com/profile/14685043408496367587noreply@blogger.comtag:blogger.com,1999:blog-13495125.post-43503748298663229692022-01-17T16:58:00.008-06:002022-01-17T17:25:09.196-06:00Difficult Conversations About Racism<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEjnc3ZDb7ON09v23NLSNCf5mp70qIx6iAqOTeKP5oDUXtzGy2bhjlFoXxTuzn_sx9G1JWgMLzS4-EqtFzdsUe_nhcVlYoz6dflMSA6OHT8CLvtHTfJUx4xSxCB37K5kAh5UD-oOdpamSGLt-4ot1_WTmLBM0Wc-rss05eVxZKH9jNt3z-WWiwg=s800" style="display: block; padding: 1em 0; text-align: center; clear: right; float: right;"><img alt="" border="0" width="320" data-original-height="800" data-original-width="800" src="https://blogger.googleusercontent.com/img/a/AVvXsEjnc3ZDb7ON09v23NLSNCf5mp70qIx6iAqOTeKP5oDUXtzGy2bhjlFoXxTuzn_sx9G1JWgMLzS4-EqtFzdsUe_nhcVlYoz6dflMSA6OHT8CLvtHTfJUx4xSxCB37K5kAh5UD-oOdpamSGLt-4ot1_WTmLBM0Wc-rss05eVxZKH9jNt3z-WWiwg=s320"/></a></div>
by Christian Sinclair (<a href="https://twitter.com/ctsinclair" target="_blank">@ctsinclair</a>)
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There are many difficult situations we encounter in palliative care and hospice. Our training and experience equip us with words and skills to explore emotion-inducing topics. Yet there are still moments many clinicians can be caught speechless, and one of those is when we encounter racist language in the midst of our work.
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If I had to pick the most influential article in 2021, it would be "<a href="https://www.jpsmjournal.com/article/S0885-3924%2821%2900150-0/" target="_blank">Power, Silence, and Debriefing: Hidden Harms When Palliative Teams Encounter Racism</a>" by Rev. Florence Moss and Dr. Kate McKillip, published in the Journal of Pain and Symptom Management in June 2021. I have shared it numerous times with colleagues and trainees, so much so, "Moss McKillip" regularly autofills on my search engine.
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I was reminded of the power of this article with Rev Moss and Dr. McKillip presented for <a href="https://www.youtube.com/watch?v=k1mLHFdBUXg" target="_blank">Friday Chalk Talk* led by Dr. Martin Bazelak this past week. </a> If you are looking for speakers for your next Grand Rounds, I would put these two on your 2022 short list.
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The article is a case based format, stemming from a real consult in which a patient used a racial slur, and there was no response in the moment. What follows is a very open portrayal of the debrief, which touches on the harm caused and the missed opportunities for responding in a way which supports the anti-racist work we should be supporting in health care. I am so appreciative of the thoughtful and honest writing by the authors. It was difficult for me to read the first few times, because I would frequently reflect on missed opportunities I have had in my career. It hurts to reflect on moments you could reduce harm to others, but you didn't. This is an important step, and it gets easier to read, because you can focus on the framework McKillip and Moss give to make better choices in the future.
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One critical point is our communication tools of empathic silence and immediate debrief are not enough to handle these situations. McKillip and Moss let us in on their inner thoughts as they work through this case. They did a lot of work together to make things better for their own future work alone and together. They could have kept this work private, but they transformed it into something that could have a much larger impact in the world. I am so appreciative. I have already put some of their work into practice.
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This article differs from other important work like the 2016 NEJM article Paul-Emelie, Smith, Lo and Fernández, "<a href="https://www.nejm.org/doi/full/10.1056/NEJMp1514939" target="_blank">Dealing with Racist Patients.</a>" Most articles focus on what to do about the care of the patient now and in the future if they ask to be reassigned. That is important to consider as well, but what I appreciate about McKillip and Moss' work is that it focuses on the team, and the role we all must have in working towards a more caring and supportive community at work.
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COI: Peer-to-peer mentorship - Mckillip, Bazelak
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*Friday Chalk Talk is a great weekly resource. I need to write about that too!
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For more <a href="https://www.pallimed.org/search/label/race">Pallimed posts about race and healthcare.</a><br />
For more <a href="https://www.pallimed.org/search/label/ethics">Pallimed posts about ethics.</a><br />
For more <a href="https://www.pallimed.org/search/label/sinclair">Pallimed posts by Dr. Sinclair click here.</a>
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<i>Christian Sinclair, MD, FAAHPM is palliative care physician working in outpatient clincs at the University of Kansas Health System in Kansas City, KS. He currently is inspired to learn more about low-car transportation planning in cities like Berlin.</i>
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Christian Sinclairhttp://www.blogger.com/profile/14685043408496367587noreply@blogger.comtag:blogger.com,1999:blog-13495125.post-24909430425074968422022-01-03T14:00:00.001-06:002022-01-03T14:48:17.584-06:00Cloaked Suffering<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEhqaoBK4grFdr6-hiTEawCeUYv2b5JER-48Bu2348FfQjaCTXFd8EEgMW32G7d00KxwyPz0vZ8bOXtlV9LnJAq1VtwhQO7RjKXrjTtKJLRTBHoOXBNm-9NXNg-Rw5iPDEH-Jf98gB9RKjNI5IyEh3s7cJQoP0QmpbnMACIlgvMpuqiAUWSxsGI=s800" style="display: block; padding: 1em 0; text-align: center; clear: right; float: right;"><img alt="" border="0" width="320" data-original-height="800" data-original-width="800" src="https://blogger.googleusercontent.com/img/a/AVvXsEhqaoBK4grFdr6-hiTEawCeUYv2b5JER-48Bu2348FfQjaCTXFd8EEgMW32G7d00KxwyPz0vZ8bOXtlV9LnJAq1VtwhQO7RjKXrjTtKJLRTBHoOXBNm-9NXNg-Rw5iPDEH-Jf98gB9RKjNI5IyEh3s7cJQoP0QmpbnMACIlgvMpuqiAUWSxsGI=s320"/></a></div>
by Lyle Fettig (<a href="https://twitter.com/FettigLyle" target="_blank">@FettigLyle</a>)
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The suffering in our hospital is cloaked by tinted windows and shiny new steel, a serene architectural specimen which betrays the internal chaos of each person who experiences illness behind each door.
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Even for people who work there, it is sometimes surreal to approach the building in its beauty with the dissonant knowledge of what can happen in all manner of disease in between the walls. It’s the perfect place to hide the devastation of a pandemic.
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Were the death and agony in the streets for all to see, perhaps the choices that are obvious to you and me would be obvious to all. How could a person not take every step they could to prevent this ongoing calamity?
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This is not the bubonic plague to be seen in the gutters but rather a plague silenced by the plastic of the tubes you have placed in many airways hoping that after days, Weeks, Months, those voices will be heard again, knowing that some will go unheard for all of eternity.
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Speak the truth with the ferocity and compassion I always hear from you. Tell the world what you have witnessed. Then go back into it with pride that no matter how your message has been received, you can rest your weary head knowing you have done the best this world will allow.
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<a href="https://twitter.com/FettigLyle/status/1475640325947412491" target="_blank">Originally published on Twitter Dec 27, 2021</a>
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<blockquote class="twitter-tweet"><p lang="en" dir="ltr">The suffering in our hospital is cloaked by tinted windows and shiny new steel, a serene architectural specimen which betrays the internal chaos of each person who experiences illness behind each door. /1</p>— Lyle Fettig (@FettigLyle) <a href="https://twitter.com/FettigLyle/status/1475640325947412491?ref_src=twsrc%5Etfw">December 28, 2021</a></blockquote> <script async src="https://platform.twitter.com/widgets.js" charset="utf-8"></script>
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For more <a href="https://www.pallimed.org/search/label/covid">Pallimed posts about COVID.</a><br />
For more <a href="https://www.pallimed.org/search/label/fettig">Pallimed posts by Dr. Fettig click here.</a>
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<i>Dr. Lyle Fettig is an Assistant Professor of Clinical Medicine in the Department of Medicine/Division of General Internal Medicine and Geriatrics. Dr. Fettig directs the IUSM Palliative Medicine Fellowship and works clinically with the Eskenazi Health Palliative Care Program.</i>
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Pallimed Editorhttp://www.blogger.com/profile/11358791266969988517noreply@blogger.comtag:blogger.com,1999:blog-13495125.post-12753879592937281332021-11-30T10:00:00.047-06:002022-05-13T10:56:42.596-05:00Say No! More - A Video Game Review<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjhd05j1zvmIkAFEP2unpUxvxjnrHpKd296y_Ro9IbH-t7dv3YkXFpmGCnjTvkWHoABTmnxRmRO2WEt4zxgOEolz7PLofGW5WjcyUK9CT7eFIRhS8Erx9QjPjG7AN7fOGsJ-olPbA/s1080/say+no+more+%25281%2529.png" style="display: block; padding: 1em 0; text-align: center; clear: right; float: right;"><img alt="" border="0" width="320" data-original-height="1080" data-original-width="1080" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjhd05j1zvmIkAFEP2unpUxvxjnrHpKd296y_Ro9IbH-t7dv3YkXFpmGCnjTvkWHoABTmnxRmRO2WEt4zxgOEolz7PLofGW5WjcyUK9CT7eFIRhS8Erx9QjPjG7AN7fOGsJ-olPbA/s320/say+no+more+%25281%2529.png"/></a></div>
by Matthew Tyler (<a href="https://twitter.com/pallidad" target="_blank">@pallidad</a>)
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Consider the last time you said “Yes” to something when you would have preferred to have said “No.” Maybe you worried saying “No” would damage a relationship. Or maybe you didn’t want to put your job at risk. In <a href="https://www.saynomo.re/" target="_blank">Studio Fizbin’s <i>Say No! More</a></i> you assume the role of a corporate intern on a quest to reclaim their lunch stolen by upper management. You go to battle with your manager, the C-suite, and beyond, wielding the power of a word never-before spoken within the walls of your office. <i>Say No! More</i> demonstrates in an over-the-top fashion how being able to say “No” can be a positive.
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Although silly on the surface, <i>Say No! More</i> addresses the matter of social conditioning. From the moment we are born, we are taught to associate the word “Yes” with being agreeable and “No” with being disagreeable. As we age, our desire to be perceived as agreeable leads us to answer “Yes” to almost any question, even when it works against our best interests. As a facilitator of serious illness discussions, I am always looking for a way to frame questions so that the person feels comfortable answering in a way that honors their genuine selves. I realize people will often reflexively answer “Yes” and so I will rework questions to remove the onus of answering “No.”
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Sharing serious news with a patient requires an environment conducive to discussion, and a big part of that is getting the timing right. A mindful clinician might first ask the patient “Is this a good time to talk?” but this phrasing risks receiving that reflexive “Yes” whether it’s actually a good time or not. We can work around this dynamic by instead asking “Is this a <i>bad</i> time to talk?” That way, the patient can give a “Yes” and will follow up with when it would be a better time, or they reply with a “No” that allows them to feel ownership of the conversation that follows. Timing is equally important when calling a family on the phone (where many serious conversations have been taking place these days). I often find clinicians diving in with difficult news the moment they hear “Hello” on the other end of the line. The obvious problem is that the person receiving the call could be in the middle of an important meeting or stuck driving in traffic. Asking “Is this a bad time?” disrupts the autopilot responses so common on distracted phone calls and creates the opportunity to either say “Yes” in a way that protects their needs in the moment or say “No” in a way that helps shift their focus to the conversation at hand.
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Clinicians wishing to address questions of life prolonging therapy will often ask their patients questions like, “Do you still want us to do everything?” or “Would you like to go home?” Both questions can be problematic as they bias towards an affirmative response. Experts in serious illness communication recommend asking patients about what matters most to them before jumping into choices. Once the patient’s values are made explicit, we can pose a question that necessitates introspection and a prioritization of values regardless of whether the answer is “Yes” or “No.” That may sound something like this: “I am hearing that spending as much time at home with your family is very important to you, but that you are also interested in this clinical trial. Would you be willing to risk that time at home for the chance to extend your life?” In this case, “No” allows the patient to establish clear boundaries on treatment to preserve what they value most, whereas “Yes” makes explicit the hierarchy of their priorities to help the clinician offer their best advice on next steps.
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Palliative care aims to help patients take control of their lives in the context of a serious illness. Creating space for patients to say “No” when needed is one way to foster that sense of control. Next time you need to have an important conversation with someone, consider how that discussion may be enriched by giving them the opportunity to <i>Say No! More</i>.
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This post has a companion piece video hosted by Digital Doc Games (embedded below). Check out the <a href="https://www.youtube.com/c/DigitalDocGames/featured" target="_blank">Digital Doc Games YouTube channel hosted by Dr. Amiad Fredman</a> for videos on how video games have a huge power to have a positive impact on people's lives.
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<iframe width="560" height="315" src="https://www.youtube-nocookie.com/embed/OMr3kgOQF64" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe>
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<i>Say No! More<a href="https://www.saynomo.re/" target="_blank"></a></i> is available to play on PC (Steam), iOS and Nintendo Switch systems.
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<iframe width="560" height="315" src="https://www.youtube-nocookie.com/embed/ZqggUZB-KTs" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe>
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For more <a href="https://www.pallimed.org/search/label/games">Pallimed posts about games.</a><br />
For more <a href="https://www.pallimed.org/search/label/media">Pallimed posts about culture and media.</a><br />
For more <a href="https://www.pallimed.org/search/label/tyler">Pallimed posts by Dr. Tyler click here.</a>
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<i>Matt Tyler is a palliative care doctor in Chicago. If he's not watching Cocomelon with his daughters, he is probably playing video games.</i>
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<b>References</b>
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1 Voss, C., Raz, T. (2017). <a href="https://bookshop.org/books/never-split-the-difference-negotiating-as-if-your-life-depended-on-it/9780062407801" target="_blank">Never split the difference: Negotiating as if your life depended on it</a>. Random House Business Books
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2 Ury, W. (2007). <a href="https://www.goodreads.com/book/show/99401.The_Power_of_a_Positive_No" target="_blank">The power of a positive No: How to say No and still get to Yes</a>. New York: Bantam Books.
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<br><br>Pallimed Editorhttp://www.blogger.com/profile/11358791266969988517noreply@blogger.comtag:blogger.com,1999:blog-13495125.post-34733476442444792652021-11-22T09:10:00.007-06:002021-11-25T06:38:23.004-06:00The Limits of Advance Care Planning<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiIAxk6iXdd-xwrfqIWbXGdJ1TW4XFi4rI3NgDF8n2qI007ZqRK4wmXKebuMgW0zYzZjzG3UKz6QYlm_ldUmpD4007mFvQ3d1dmeawim89zQxbRjhvBctyHkM1b2v3yNlLY7vFmEA/s800/limits+of+acp.png" style="display: block; padding: 1em 0; text-align: center; clear: right; float: right;"><img alt="" border="0" width="320" data-original-height="800" data-original-width="800" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiIAxk6iXdd-xwrfqIWbXGdJ1TW4XFi4rI3NgDF8n2qI007ZqRK4wmXKebuMgW0zYzZjzG3UKz6QYlm_ldUmpD4007mFvQ3d1dmeawim89zQxbRjhvBctyHkM1b2v3yNlLY7vFmEA/s320/limits+of+acp.png"/></a></div>
by Michael Pottash (<a href="https://twitter.com/mpottash" target="_blank">@mpottash</a>)
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Several luminaries of palliative care –<a href="https://jamanetwork.com/journals/jama/fullarticle/2785148?utm_source=facebook&utm_campaign=content-shareicons&utm_content=article_engagement&utm_medium=social&utm_term=101021#.YWM9CQ0Hr2A.facebook" target="_blank"> writing in the Journal of the American Medical Association</a> – recently outlined a strong case against advance care planning, referring specifically to advance directives and the efforts to plan for a future illness state. Planning for the end of life and documenting preferences was meant to improve “goal-concordant care” by providing a road map of a person’s wishes for the end of their life when they can no longer communicate for themselves.
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When the United States Supreme Court ruled against the family of Nancy Cruzan, they effectively placed a limit on the right to refuse medical treatment for those unable to speak for themselves, declaring that while there may be a “right to die” even for an incapacitated patient, the state may require clear evidence to overrule its interest in the sanctity of life. In addition to the changing legal landscape came our growing anxieties around medical technology and its encroachment on the boundary between life and death. We have become enamored by the idea that clearly documented preferences, whether in a legal document or in a medical chart, could save us from some future purgatory between life and death.
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As the advance directive industrial complex grew, it soon became en vogue to claim that the ubiquitous completion of these documents could even curb healthcare spending. The common wisdom became: 1) people don’t want aggressive medical interventions at the end of life - they want to die peacefully at home, and 2) medical interventions at the end of life (that people don’t really want anyway) is expensive, so 3) if we can get people to document their preferences, we can save a lot of money by avoiding unwanted, expensive medical interventions at the end of life.
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The drum of discontent over advance care planning, especially advance directives, has been beating for a while now. In <a href="https://www.jpsmjournal.com/article/S0885-3924%2818%2930283-5/fulltext" target="_blank">reviewing the landscape of evidence</a>, it seems that advance directives may not be able to consistently influence end of life care in a measurable way. Therefore, it is not surprising that the theorized cost savings to the healthcare system <a href="https://www.nejm.org/doi/full/10.1056/nejm199402243300806" target="_blank">never materialized</a>. Not only do the vast majority of Americans <a href="https://www.healthaffairs.org/doi/10.1377/hlthaff.2017.0175?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed" target="_blank">not complete advance directives</a>, but there is good evidence that they <a href="https://agsjournals.onlinelibrary.wiley.com/doi/abs/10.1111/j.1532-5415.2000.tb03146.x?sid=nlm%3Apubmed" target="_blank">don’t actually want their documented preferences to be followed</a>. They would rather have their doctor and someone they trust make those decisions in real time.
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More concerning, focusing on advance directives <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/hast.867" target="_blank">may not even be ethical</a>. It asks people to make decisions for their future disabled selves – often focusing on function and independence. Yet we know that people are generally more resilient than they believe and <a href="https://www.jstor.org/stable/24290048" target="_blank">adapt to all kinds of changed and debilitated states</a>. We also know that <a href="https://www.sciencedirect.com/science/article/abs/pii/S0277953698004110?via%3Dihub" target="_blank">able bodied people tend to discount</a> the quality of life of someone living with a disability, even when that person is our future selves. This issue alone has driven a wedge between the disability community and medicine, and continues to be a <a href="https://journals.sagepub.com/doi/10.1177/082585970602200307" target="_blank">blemish</a> on the otherwise inclusive culture of palliative care. There are serious ethical problems in asking people to decide today what their future selves would consider a life worse than death.
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In the JAMA article, the authors recommend that advance directives and future-oriented conversations be deemphasized in favor of 1) documenting a healthcare surrogate - someone to relay our values and guide clinicians based on what they believe would be in our best interests - and 2) training clinicians to have “high-quality discussions” in the moment, when “actual (not hypothetical) decisions must be made.” That makes a lot of sense. And yet, we still require a framework for how to care for our patients <i>before</i> critical illness and end of life, for those patients still living with serious illness. What are the metrics of success if not completing advance directives or documenting future preferences? In our outcomes obsessed healthcare system, where is the value in informing our patients of what to expect in the future?
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Perhaps a better framework for thinking about these future-oriented conversations is to be found in the work being done as part of <a href="https://www.ariadnelabs.org/serious-illness-care/" target="_blank">Ariadne Labs Serious Illness Care Program</a> and others like it. This program is training clinicians to have Serious Illness Conversations with their patients <i>before</i> they end up in the final stage or in intensive care. Instead of measuring success in <i>outcomes</i>, such as an advance directive or a documented preference, they want to know if patients and their clinicians find these conversations valuable. For example, <a href="https://onlinelibrary.wiley.com/doi/10.1002/cam4.3102" target="_blank">they ask patients</a>: 1) Did this conversation give you a greater (or lesser) sense of control? 2) Did you get the right amount of information from this discussion? And they ask clinicians: 1) Did you learn something surprising about your patient? 2) How did this discussion affect your patient’s emotional state? 3) Did your patient have a good understanding of prognosis? They seem to favor <i>process</i> questions: Were these conversations feasible, acceptable, and were you satisfied?
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This approach to serious illness conversations – focusing on the process of informing and tending to emotion in lieu of attempts to influence future outcomes – may be a big (and possibly disappointing) paradigm shift for our outcomes-driven health system. Occasionally, Medicine’s role is to heal or to cure, sometimes it is to ease suffering, and often, all it can do is inform and provide counsel. It can be hard for us clinicians to realize that we cannot fix. Sometimes the only reason to do something is because it is what patients expect, it is what they need, and because it is the right thing to do. Is that enough of a reason to invest resources in hiring people to do this work, and to train others to become proficient? Though it may not lead to universal “goal-concordant care” or to cost savings, is it enough for us to do it because it is right? And can we live with that?
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For more <a href="https://www.pallimed.org/search/label/acp">Pallimed posts about Advance Care Planning.</a><br />
For more <a href="https://www.pallimed.org/search/label/pottash">Pallimed posts by Dr. Pottash click here.</a>
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<i>Michael Pottash MD MPH is a Palliative Medicine Physician at MedStar Washington Hospital Center and Associate Professor of Medicine at Georgetown University School of Medicine.
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<br><br>Pallimed Editorhttp://www.blogger.com/profile/11358791266969988517noreply@blogger.comtag:blogger.com,1999:blog-13495125.post-45524753095272625032021-09-17T14:00:00.003-05:002023-06-23T03:48:31.464-05:00Roger Chou’s Undisclosed Conflicts of Interest: How the CDC’s 2016 Guideline for Prescribing Opioids for Chronic Pain Lost Its Clinical and Professional Integrity<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhLwZrLxklvPiIlan_ZZtbP9edAKWd0DOBq5WCs24mJ4bPwy1VGV7JkYdp1EB9KtUejGWOWepS4ZiB3jjGEuZBC5CEm_Oax7JETwQHuY4oIqSxK2TGXsGm4g1yM8WPva6dbKgplsA/s1080/OUD+Post.png" style="display: block; padding: 1em 0; text-align: center; "><img alt="" border="0" width="320" data-original-height="1080" data-original-width="1080" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhLwZrLxklvPiIlan_ZZtbP9edAKWd0DOBq5WCs24mJ4bPwy1VGV7JkYdp1EB9KtUejGWOWepS4ZiB3jjGEuZBC5CEm_Oax7JETwQHuY4oIqSxK2TGXsGm4g1yM8WPva6dbKgplsA/s320/OUD+Post.png"/></a></div>
by Chad D. Kollas MD, Terri A. Lewis PhD, Beverly Schechtman and Carrie Judy
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<i>“I'm present. Uh … I do have a conflict. I receive funding to conduct reviews on opioids, and I'll be recusing myself after the um, director's, uh, um, um, uh… update.” </i>
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- Dr. Roger Chou, Center for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control (NCIPC) Board of Scientific Counselors (BSC) Meeting Friday, July 16, 2021.
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<b>Introduction</b><br>
For those familiar with the controversial relationship between the anti-opioid advocacy group, Physicians for Responsible Opioid Prescribing (PROP, recently renamed, Health Professionals for Responsible Opioid Prescribing), and the Centers for Disease Control’s CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016, (2) (hereafter called “the 2016 Guideline”), Dr. Roger Chou’s disclosure represented a stunning admission (3, 4). Chou had originally announced his intention to help influence opioid policy in a 2011 article that he co-authored with PROP’s founders (5), and he was a bold signatory to PROP’s 2012 Petition to the Food and Drug Administration (FDA) to change opioid labeling (6; See Figures 1a and 1b: First page and signatory page.)
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Figure 1a: First Page of PROP Petition to FDA
<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj78efZCF6cNMhVSg6L2RMb1mWA90HDUlkxJwUeM2q9KR9NIUB5Kcb8ogWpEW1K0KMygevmCaYcOhWP0xbfKEJxZDbPynoZXwWkOJ7DHBHaYq67G7n_y9geE8kz_fQl_7Ei9EgKSA/s1036/fig1a.jpg" style="display: block; padding: 1em 0; text-align: center; "><img alt="" border="0" width="320" data-original-height="672" data-original-width="1036" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj78efZCF6cNMhVSg6L2RMb1mWA90HDUlkxJwUeM2q9KR9NIUB5Kcb8ogWpEW1K0KMygevmCaYcOhWP0xbfKEJxZDbPynoZXwWkOJ7DHBHaYq67G7n_y9geE8kz_fQl_7Ei9EgKSA/s320/fig1a.jpg"/></a></div>
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Figure 1b: Signatory Page of PROP Petition to FDA
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Through his participation in these PROP activities, Chou established himself as a significant contributor to PROP efforts. Yet he never formally served as a leader or member of PROP, and until the CDC NCIPC-BSC Meeting on July 16, 2021, Chou avoided all allegations of conflicts of interest (COI) between his opioid research and co-authorship of the 2016 Guideline, unlike several other PROP members (2). Given that the CDC had strict reporting guidelines for COI’s for those involved in the creation of the 2016 Guideline, Chou’s startling disclosure raises many important questions about his involvement in the original publication. It also raises many concerns about his role in the creation of any “draft, updated and/or expanded Guideline (hereafter called the “2022 Guideline”) that might arise from such conflicts (7).
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Did Chou fail to disclose a prior conflict of interest (COI) when he drafted the 2016 Guideline? Wouldn’t such a failure to disclose a past COI undermine the integrity of that Guideline? Does Chou’s recent COI disclosure compromise the integrity of the upcoming 2022 Guideline, even before its publication? In making such a mysterious disclosure, was Chou recusing himself from the July 16, 2021, CDC NCIPC/BSC meeting only, or did his statement refer to a recusal from the 2022 Revised and Expanded Guideline entirely? The answers to these questions have profound implications for the CDC’s Opioid Prescribing Guideline’s professional integrity and clinical credibility. This could, in turn, substantially bring into question the CDC’s entire national opioid policy, both in how it was applied in the past, as well as how it might be viewed in the future.
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<b>PROP’s Beginnings (2000-2015): Washington State’s War on Opioids in Labor and Industries (the state’s Workman’s Compensation Program)</b><br><br>
<i>The AMDG Pain Guidelines</i><br><br>
Chou’s entanglement with competing interests began years before the CDC began the process of creating its 2016 Guideline, rooted in the state of Washington’s war on opioids prescribed to Labor and Industry recipients. In 2005, Gary Franklin, MD, MPH, Director of the Labor and Industry Program, who would later become PROP’s Vice President of State Regulatory Affairs, published an article alleging that “that tolerance or opioid-induced abnormal pain sensitivity may be occurring in some workers who use opioids for chronic pain (9).” He concluded that “[o]pioid-related deaths in this population may be preventable through use of prudent guidelines regarding opioid use for chronic pain (7).” Franklin also served on the Washington State Agency Medical Directors Group (AMDG) via the Washington State Department of Labor and Industries (9).
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By 2007, the Washington State Agency Medical Directors Group (AMDG) published its “Interagency Guideline on Opioid Dosing for Chronic Non-Cancer Pain (8),” which was updated in 2010 and 2015 (11). This guide introduced the concept of a hard dosing threshold for opioid analgesics, despite an FDA criticism that the concept lacked scientific support and encouraged reduced opioid prescribing or tapering of opioid doses based on these arbitrary thresholds (2, 11). It was also used by the Washington State Department of Labor & Industries to guide prescribing for the state’s “Medicaid patients, Workers’ Compensation recipients, and state employees,” which led to increased use of methadone, which Franklin selected as a less expensive alternative to other opioid analgesics (12).
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<i>Harms from the Workmen’s Compensation Program and AMDG Pain Guidelines</i><br><br>
The harms from the AMDG Pain Guidelines as applied to Washington’s Workers’ Compensation and Medicaid programs had become evident by 2009. Scott Fishman, MD, and Lynn Webster, MD publicly criticized AMDG’s hard dosing threshold for opioid analgesics, particularly regarding the use of methadone (15) They noted that while a “starting dosing regimen of 10 mg of methadone four times per day, as allowed by most conversion tables, would fall below the 120-mg morphine equivalent level… this amount of methadone [had] been fatal in some instances (15).” They further noted that the AMDG failed to collaborate with pain management experts when creating its guideline and cited formal opposition to the AMDG Guideline by multiple professional pain societies: the American Academy of Pain Medicine (AAPM), the American Pain Foundation (APF) and the American Pain Society (APS) (14).
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In a Pulitzer-prize winning series published in the Seattle Times, investigative reporters Michael J. Berens and Ken Armstrong reported that while encouraging prescribers to use methadone may have saved the state of Washington millions of dollars, it also resulted in the deaths of many of the state’s Medicaid recipients (14, 16). The series highlighted the egregious harms suffered by Washington’s “Medicaid patients, Workers’ Compensation recipients and state employees” due to increased use of methadone, encouraged by Franklin via the AMDG Guideline (12). Their reporting prompted the state of Washington to “issue a public health advisory that singles out the unique risks of methadone” as contributing to the deaths of at least 2,173 people between 2003 and late 2011 (14). Despite the identification of these recognized harms, the forces behind the creation of the AMDG Guidelines broadened their efforts to reduce opioid prescribing when they joined forces with PROP, a group whose creation Chou had announced in a co-authored article in 2011 (4).
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<b>Exploring Chou’s COIs in co-authoring the Centers for Disease Control’s CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016 (2008-2018)</b><br><br>
<i>The Significance of the CDC’s Reporting Requirements for Conflicts of Interest</i><br><br>
Prior to participating in the creation of the 2016 Guideline, CDC stated the following with regard to handling potential conflicts of interest (COIs):<br><br>
• Experts must reveal possible conflicts of interest, such as financial relationships with industry, intellectual preconceptions, or previously stated public positions (18).<br><br>
• Experts could not serve if they had conflicts that might have a direct and predictable effect on the recommendations (Italics ours, 18).<br><br>
• They ‘excluded experts who had a financial or promotional relationship with a company that made a product or that might be affected by the guideline.’ (18).<br><br>
• They had reviewed potential nonfinancial conflicts carefully (e.g., intellectual property, travel, public statements, or positions, such as congressional testimony) to determine if the activities would have a direct and predictable effect on the recommendations (18).<br><br>
• They determined the risk of these types of activities to be minimal for the identified experts (18).<br><br>
• All experts completed a statement certifying that there was no potential or actual conflict of interest (18).<br><br>
• Activities that did not pose a conflict (e.g., participation in Food and Drug Administration [FDA] activities or other Guideline efforts) were disclosed (18).<br><br>
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Based on this, CDC had two main categories of COIs for which it excluded participation in the creation of the 2016 Guideline: 1) financial conflicts and 2) non-financial conflicts, specifically a conflict that “might have a direct and predictable effect on the recommendations (18).” CDC originally published that <i>no members</i> (italics ours) of the 2016 Guideline Core Expert, Peer Reviewer, or Technical Expert groups had any COI’s that were in violation of CDC’s conflicts policies. However, years after the 2016 Guideline was published, members of PROP eventually disclosed multiple serious conflicts of interest. For example, PROP President, Jane Ballantyne, MD, disclosed “that she has served as a paid consultant to Cohen Milstein Sellers and Toll, PLLC, and has special advisory committee responsibilities on the Food and Drug Administration (FDA) Risk Evaluation and Mitigation Strategies Committee (18).” PROP Board Member, Gary Franklin, MD, MPH, disclosed “authorship of the AMDG Interagency Guideline on Prescribing Opioids for Pain (18).” Otherwise, the Core Expert Group (CEG) members and Opioid Guideline Workgroup (OGW), both of which included Chou, a PROP ally, “disclose[d] that they have no financial conflicts of interest (4,18).” Of note, Roger Chou, also disclosed no non-financial COIs related to the professional content of his contributions to the 2016 Guideline (18). Thus, it is now clear that the CDC did not hold the authors and contributors to the 2016 Guideline to its own clearly stated conflicts of interest and ethical policies.
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<i>Chou’s Non-Financial COIs in the 2016 Guidelines: Co-Authorship of Opioid Reviews and Professional Criticisms Regarding His Flawed Methodologies</i><br><br>
In 2008, Chou authored an article for a special issue of Pain Medicine about interpreting and applying systematic reviews and clinical practice guidelines (19), an activity that one would have reasonably expected to “have a direct and predictable effect on the recommendations (18)” on the 2016 Guideline. A group of physicians, including the lead author of four articles in that same special issue of Pain Medicine (20-23), criticized Chou’s misinterpretation of pain guidelines by the American Society of Interventional Pain Physicians (ASIPP) in the special issue (24):<br><br>
• They noted that Chou had “focused solely on randomized clinical trials; consequently, [the] evidence may be misinterpreted (24).” <br><br>
• They further explained that it “is not the stringent standard which shows the evidence, or lack therefore of, but <i>developing guidelines without appropriate expertise on the subject and randomized trials performed by non-specialist academicians</i> (Italics ours, 24).<br><br>
• They concluded that “[w]ithout any proof that evidence-based medicine is effective and it is based on evidence, it will be best if evidence synthesizers <i>follow the rules appropriately, rather than injecting personal, biased opinions</i> (Italics ours, 24.)” <br><br>
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Similarly, in 2010, a group of authors again took issue with Chou’s interpretation (25) of the American Pain Society (APS) Clinical Practice Guidelines for Interventional Techniques (23):<br><br>
• Specifically, they wrote that Chou “utilized multiple studies inappropriately and… excluded appropriate studies (26).” <br><br>
• They also asserted that Chou failed to eliminate bias in his evaluations of the APS Clinical Practice Guidelines for Interventional Techniques (24) …<br><br>
• Which one would again reasonably expect to “have a direct and predictable effect on the recommendations (21)” on the 2016 Guideline.<br><br>
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Additionally, in 2014, Chou co-authored a systematic review and critical appraisal of guidelines for chronic pain (27). The article concluded, “Despite limited evidence and variable development methods, recent guidelines on chronic pain agree on several opioid risk mitigation strategies, including upper dosing thresholds; cautions with certain medications; attention to drug-drug and drug-disease interactions; and use of risk assessment tools, treatment agreements, and urine drug testing (27).” Ironically, in 2013 Chou had co-authored an AHRQ-sponsored article in which he stated, “Since evidence syntheses depend on the published literature accurately representing what’s known about medical therapies, <i>reporting biases threaten the veracity of what we know</i> (italics ours, 28). This indicates that Chou understood reporting bias, co-authored reviews of guidelines for managing chronic pain, but failed to report what a reasonable individual would correctly interpret as a conflict that “might have a direct and predictable effect on the recommendations,” prior to or during his co-authorship the 2016 Guideline (18). Under the CDC’s rules for inclusion in the creation process of its 2016 Guideline, Chou should have disclosed these conflicts before contributing as a co-author, and <i>these conflicts should have disqualified him from participating in the process of creating the 2016 Guideline</i> (Italics ours.) This is particularly concerning when taken in context with concerns about the strength of evidence upon which the 2016 Guideline were based. As the American Medical Association noted, “It seems incongruous that virtually all of the specific guidelines carry a graded recommendation that CDC believes should ‘apply to all patients with chronic pain and that… most patients should receive the recommended course of action,’ given the limitations of the evidence, <i>especially where CDC experts’ opinions are the essential foundation for the recommendation</i> (Italics ours; 29).”
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<i>Chou’s Financial COIs in Both Pain GLs: Funding from PROP/Group Health/Kaiser, AHRQ and the CDC Foundation</i><br><br>
Chou also shared financial conflicts through his relationship with PROP and its funding, which “might have a direct and predictable effect on the recommendations” of the 2016 Guideline (18). As mentioned earlier, Chou was a co-author of a 2011 journal article that announced the formation of PROP, and while PROP has resolutely avoided identifying its donors over the last decade, Chou’s group received funding from Group Health Foundation, which lead-author, Michael Von Korff, disclosed as a potential conflict of interest at the time (4). The Group Health Foundation and PROP co-sponsored a National Summit on Opioid Safety on October 16, 2012 (30), during which Chou provided the keynote address, acknowledged funding from the Agency for Healthcare Research and Quality (AHRQ), and disclosed a financial relationship with Palladian Health for implementation of low back pain guidelines (31).
<br><br>
Palladian Health described itself as “comprehensive muscular skeletal health care company that integrates physical therapy, chiropractic, health and fitness with patient care advocacy to improve clinical and economic outcomes,” and listed Chou as a member of its Clinical Advisory Board (32). This represented a conflict with both financial and non-financial implications for his co-authorship of the 2016 Guideline. More importantly, Oregon Health and Science University (OHSU), Chou’s employer, announced on August 31, 2012, that it had received from AHRQ a five-year contract to serve as an Evidence-Based Practice Center, which funded Chou’s work (33). In the 2016 Guideline, Chou acknowledged that he had represented the Oregon Health and Science University with funding from his 2014 systematic review and critical appraisal of guidelines for chronic pain coming from AHRQ Grant HS17954 (18). This marked the beginning of an early funding loop between PROP (through Group Health Foundation, at that time) and AHRQ for work that Chou used to create the 2016 Guideline.
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Over the next several years, Chou would expand this tangled web of financial conflicts of interest by adding the CDC Foundation as an indirect funder for his clinical reviews on opioid analgesics. According to its website, “The CDC Foundation is an independent nonprofit and the sole entity created by Congress [in 1992] to mobilize philanthropic and private-sector resources to support the Centers for Disease Control and Prevention’s critical health protection work (34, 35).” Of note, as part of its policy to avoid conflicts of interest, the CDC Foundation is prohibited from “[p]artnership with an organization that represents any product that exacerbates morbidity or mortality when used as directed (36).
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Kaiser Permanente acquired Group Health Cooperative in 2017 and formed a new 501(c)(4) foundation from the proceeds from the acquisition, which “was previously part of Group Health Cooperative [but would then] operate collectively as ‘Group Health Foundation’ (37, 38).” The Kaiser Foundation Hospitals Centers for Health Research, which is part of the Kaiser Permanente Center for Health Research (39), is listed as a philanthropic donor to the CDC Foundation (40). In retrospect, Kaiser Permanente attended, as an invited guest, a 2015 online CDC webinar during which the CDC unveiled the 2016 Guideline, which was met with fierce criticism from other medical professional stakeholders (41). By the time the 2016 Guidelines were released, the CDC Foundation was firmly established as part of the Chou self-funding loop already created by PROP/Group Health/Kaiser Permanente and AHRQ.
<br><br>
On November 20, 2018, Chou’s employer, the Oregon Health and Science University, received a delivery order, funded by the AHRQ under Evidence-based Practice Centers, with a potential value of $500,000 (42). The streaming of this funding became clearer in December 2019, when the AHRQ awarded the Pacific Northwest Evidence-based Practice Center (EPC), a program within OHSU directed by Roger Chou, a five-year contract “to develop evidence reviews to inform healthcare decision-making [sic]; promote the uptake of evidence, including health systems; and invest in research methods to improve the quality, usefulness and efficiency of evidence reviews (43).” Chou publicly acknowledged his funding from AHRQ in a presentation at AMDG's "Patient-Centered Approach to Chronic Opioid Management Conference," held on August 9, 2019 (45). Chou, again publicly, albeit in a quiet, subtle way, acknowledged his AHRQ funding as a relevant financial COI in a correction to an article published in Annals of Internal in November 2019 (46, 47). The full extent of Chou’s COI disclosure is only revealed when one follows the link to the article’s complete International Committee of Medical Journal Editors (ICMJE) Disclosure of Interest form (48). Furthermore, while Chou disclosed his financial relationships with AHRQ and CDC related to “funding to conduct reviews on opioids for chronic pain,” he characterized this conflict as relevant activity outside of the submitted work (48). In doing so, he avoided being directly identified as failing to disclose a COI in the Correction published by Annals of Internal Medicine, which explicitly called out PROP members Anna Lembke, MD and Jane Ballantyne, MD, instead (47). More specifically, Ballantyne finally disclosed her involvement with PROP and her consultative fees for consulting in the multibillion-dollar Multi District Opioid Litigation. Lembke also took this belated opportunity to disclose her involvement with PROP (47, 48). They also clarified that the article had misrepresented PROP as “A 501(c)(3) charitable organization (47, 48),” although “PROP is not a registered charity with the Internal Revenue Service (49).”
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<b>The Yet-to-be-Released, Revised and Expanded 2022 Guideline (2018-Present)</b><br><br>
By the end of 2019, AHRQ had delivered the full amount of its $500,000 award to OHSU for the work done by Chou’s Pacific Northwest EPC (50), and unbeknownst to anyone but the CDC, Chou had moved on to co-authoring the expanded 2022 Guideline. Just a few months later, in April 2020, PROP and Chou were again linked to an AHRQ-funded study examining the “effectiveness of opioids in treating chronic pain (51).” In trying to determine whether PROP and Chou would be involved in writing the 2022 Guideline, Pain News Network filed a request to CDC under the Freedom of Information Act (FOIA). However, PNN received 1,500 pages of documents “so heavily redacted they were completely blank (52, 53; See Figure 2 Below). PNN has filed an appeal for the CDC’s violations of this FOIA request.
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Figure 2: CDC’s Redacted Replies to the FOIA Request from PNN
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In June 2021, the AHRQ solicited public comments on its Draft Report on Integrated Pain Management Programs, although the draft report is no longer available for review (53, 54). Many stakeholders submitted review comments, including the lead author on this article, who expressed a concern about the AHRQs policy for handling potentials COIs in its report, specifically AHRQ’s statement that “Technical Experts must disclose any financial conflicts of interest greater than $5,000 and any other relevant business or professional conflicts of interest. Because of their unique clinical or content expertise, individuals with potential conflicts may be retained. The TOO and the EPC work to balance, manage, or mitigate any potential conflicts of interest identified (55).”
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A month later, during the Roll Call for the Center for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control (NCIPC) Board of Scientific Counselors (BSC) Meeting, Roger Chou disclosed a COI related to receiving “funding to conduct reviews on opioids (1).” In the BSC-NCIPC meeting’s immediate aftermath, participants posted written comments that cited Chou’s COI disclosure as a cause for questioning the legitimacy of his role in co-authoring both sets of Opioid Prescribing Guidelines, especially because of his long-term relationship with PROP (2, 56). Advocate Tamera Lynn Stewart offered live comments during the meeting that bluntly addressed concerns about Chou’s financial COIs (57): “Chou’s been involved in calling for opioid guidelines or restrictions since around 2011. The CDC gets funding for these guidelines, the CDC pays AHRQ to write reviews on which these guidelines are going to be based. AHRQ not only contracts with Dr. Chou to conduct reviews of the opioid studies, but Chou also helped set the AHRQ priorities. Chou is one of the five authors who wrote the draft of the [CDC Opioid Prescribing] Guidelines based on the reviews <i>he was paid to create</i>. Finally, Chou is on the Board of Scientific Counselors, who approves or denies any opposition comments from the (Opioid) Working Group and, being on the BSC, Chou has a say in the final approval of the Guidelines themselves. All of this, and there’s no mention of a conflict of interest until today, July 16th, around 9 AM (57).”
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Ultimately, the Opioid Work Group (OWG) of the CDC NCIPC-BSC expressed multiple serious concerns about the 2022 Guideline, “warning the CDC that a draft revision of its 2016 Opioid Prescribing Guideline is focused too heavily on the risks of taking opioid medication, with not enough attention paid to the benefits that opioids have for many pain patients (58).” Chou’s COI disclosure and recusal from the CDC BSC-NPIPC meeting on July 16, 2021, also had many stakeholders wondering whether this signaled an end to his involvement in the further development and roll-out of the 2022 Guideline (1). The answer came at the next scheduled meeting of the CDC BSC-NPIPC, when, on July 29, 2021, during the Roll Call, Chou listed himself as, “Present, no conflicts (59).” This implies that his COI disclosure and self-recusal during the CDC NCIPC-BSC Meeting on July 16, 2021 (1), was meant only for that meeting.
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<b>Growing Evidence of Emerging Harms from the CDC Pain Guidelines<br></b><br>
<i>Harms from Opioid Tapering<br><br></i>
By early 2018, it became increasingly clear to clinicians that misapplication of the Chou co-authored 2016 Guideline had begun to result in serious patient harms (60). This included concerns about a growing number of “suicides within and outside of the Veterans Affairs Healthcare System in the United States” from forced or involuntary tapers off opioid analgesics (60). In response to growing reports of patient harms from misguided opioid policies, in November 2018, the American Medical Association adopted a new policy that opposed hard dosing limits for opioid analgesics, encouraged individualized care when prescribing opioids, and called for the AMA to advocate against ongoing misapplication of the 2016 Guideline (61). By March 2019, an array of medical professional stakeholders had submitted written requests to CDC to speak out against misapplication of its 2016 Guideline, especially regarding their opposition of involuntary opioid tapers due to rising concerns about patient harms (62-64). These efforts prompted both the Food and Drug Administration (FDA) and the CDC to issue public announcements opposing the sudden discontinuation of opioid pain medicines and misapplication of the 2016 Guideline (65-67).
<br><br>
Despite these warnings, researchers have documented growing clinical evidence of patient harms arising from CDC’s opioid policies. In May 2019, Medicaid patients in Vermont who experienced “faster rates of opioid tapering” suffered from “a greater probability of adverse events” than those not tapered or tapered more slowly (8). An August 2019 study noted that opioid tapering was associated with termination of care in 78 of 207 cases (38%), prompting the authors to recommend caution when considering tapers and calling for more research to “fully understand the risks and benefits of opioid tapers (69).” By March 2020, a group researching patients in the Veterans Health Administration observed that “patients were at greater risk of death from overdose or suicide after stopping opioid treatment, with an increase in the risk the longer patients had been treated before stopping (70).” They further noted that “strategies to mitigate the risk in these periods are not currently a focus of guidelines for long term use of opioids (70).” Results such as these prompted a group of clinicians to conclude in June 2020 that policies mandating nonconsensual opioid dose reductions are “not justified clinically or ethically (71).” More recently, a retrospective cohort study of pharmacy claims and enrollment data found that “among patients prescribed stable, long-term, higher-dose opioid therapy, tapering events were significantly associated with increased risk of overdose and mental health crisis (72).
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<i>Harms to Patients with Cancer Pain or Receiving Palliative Care<br><br></i><br>
Of greater concern than harms from tapers, several 2021 studies suggest that misapplication of the 2016 Guideline has begun to affect patients who were not intended targets for the 2016 Guidelines: patients with cancer pain or those receiving palliative care. Specifically, “the Guideline [was] not intended for patients undergoing active cancer treatment, palliative care, or end-of-life care because of the unique therapeutic goals, ethical considerations, opportunities for medical supervision, and balance of risks and benefits with opioid therapy in such care (2).” For reasons that were not clarified by its authors, the 2016 Guideline apply to “cancer survivors with chronic pain who have completed cancer treatment, are in clinical remission, and are under cancer surveillance only (2),” without considering legacy status or the frequent presence of well-recognized chronic, cancer-related pain syndromes, which often require multi-modal care for sufficient management, including opioid analgesia, when medically appropriate (73).
<br><br>
In a recent study examining prescriptions dispensed to patients with painful bone metastasis from active cancer using a large commercial claims database, opioid prescribing declined significantly between 2011 and 2017 (74). The authors expressed concerns that claims data did “not provide information regarding clinical indication or appropriateness of opioid prescriptions,” and expressed worry that a decline in opioid prescribing to this group of patients may lead to “a rising rate of undertreated pain (74).” A similar study examined Emergency Department (ED) visits by patients dying from cancer and observed that “opioid use among patients dying of cancer has declined substantially from 2007 to 2017. Rising pain-related ED visits suggests that EOL cancer pain management may be worsening (75).” Furthermore, a recently published study that used structured interviews of patients with advanced cancer found that “the US opioid epidemic has stigmatized opioid use and undermined pain management in individuals with advanced cancer (76).” Despite growing evidence of increasing harms to patients, the CDC has not issued any additional, substantive announcements since April 2019 (67). In fact, despite acknowledging inaccuracies in its own overdose death data, the CDC recently doubled down on rhetoric about prescription opioids: “Regardless of the method used to calculate the total numbers, prescription opioids continue to be involved in a significant proportion of drug overdose deaths (77).”
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<b>Where Should We Go from Here?</b><br><br>
In this article, we have provided substantial evidence that Roger Chou’s conflicts of interests, undisclosed to the public before the July 16, 2021, had “a direct and predictable effect on the recommendations” contained within the 2016 Guideline, the very language used by the CDC to define a relevant conflict. By virtue of his COI disclosure on July 16, 2021, Chou’s role as a co-author and reviewer of the 2022 Guideline has compromised the professional and clinical integrity of the 2016 Guidelines, and the entire creation process of the Guideline has undermined the credibility of the CDC. Put simply, Roger Chou has been placed in the position of “advocating his own work as national healthcare policy (78).” Despite this, when confronted by stakeholders about harms arising from misapplication of the Pain Guidelines, the CDC response was limited at best (67) or defiant at worst (78).<br><br>
Given this, we offer the following robust recommendations, several of which enjoy the support of prominent stakeholders seeking balanced opioid policy (79, 80):<br><br>
<b> 1) </b>The CDC should immediately rescind the most harmful or misapplied portions of the 2016 Guideline. This should include renouncing and rescinding arbitrary dosing thresholds, commonly referred to as MME, by health insurers, state and federal governments and pharmacies (81). It should also include a ban against involuntary opioid tapers.<br><br>
<b> 2) </b>The CDC should announce its strong commitment to balanced opioid policy, including individualized care for patients with chronic pain, explicitly acknowledging that some patients with chronic pain – especially those with serious illness – may benefit from treatment of opioid analgesics when medically appropriate.<br><br>
<b> 3) </b>The CDC should suspend indefinitely any plan to implement its 2022 Guideline, which are currently expected to be published in the Federal Register in late 2021. (82).<br>
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In addition to these measures, we call on the United States Congress or the U.S. Department of Justice to investigate Roger Chou, PROP and the Centers for Disease Control to determine whether they violated any federal laws or policies when creating either the 2016 or the expanded 2022 Opioid Prescribing Guidelines. We also encourage legal scholars to examine the harms inflicted upon patients with chronic pain as result of the 2016 Guideline, or from their misapplication, to determine whether these harms could be remedied through litigation. Undoing the ongoing harms of the CDC’s Opioid Prescribing Guideline for Chronic Pain and preventing further harms from the expanded 2022 Guideline - which were drafted with all the same ethical conflicts of the 2016 Guideline yet will affect even more patient populations - is an imperative for all invested in public health and the treatment of pain. Undoing the harms of the CDC Pain Guidelines represents a critical step in restoring balanced pain policy, which must include access to judiciously prescribed opioid analgesics, to the millions of Americans living with chronic pain every day of their lives.
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<b>About the Authors</b>
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Lead author, <b>Chad Kollas</b>, serves as the Medical Director for Palliative and Supportive Care at the Orlando Health Cancer Institute in Orlando, FL. He can be reached by e-mail at chad.kollas@orlandohealth.com or via Twitter at @ChadDKollas.
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<b>Terri A. Lewis</b> serves in Rehabilitation and Mental Health Counseling, National Changhua University of Education (NCUE), in Changhua, Taiwan/Republic of China.
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<b>Bev Schechtman</b> is a chronic pain and illness patient who has spent the last four years volunteering as a patient advocate. She is currently the VP of the non-profit, The Doctor Patient Forum, and she has been with the volunteer organization, Don't Punish Pain, since its inception in 2017. She is a passionate researcher and advocate and hopes to give a voice to those in pain.
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<b>Carrie Judy</b> is an unpaid contributor and researcher at The Doctor Patient Forum.
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<b>Competing Interests</b>
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Dr. Kollas currently serves as the Secretary of the Board of Directors of the American Academy of Hospice and Palliative Medicine (AAHPM). He also serves as the AAHPM Delegate to the American Medical Association (AMA) House of Delegates, he is the Chair of the AMA Pain and Palliative Medicine Specialty Section Council and is a member of the AMA Opioid Task Force. Dr. Kollas has provided testimony at a 2004 Congressional Hearing on OxyContin. Dr. Kollas has served as a medical expert witness in cases involving opinions regarding the standard of care in internal medicine and hospice and palliative medicine. He has received educational research grants from the AMA Education and Research Foundation, Geisinger Clinic and M. D. Anderson Cancer Center Orlando. He serves as the editor for the Advocacy section of AAHPM Quarterly and is a member of the Editorial Advisory Board and review for the Journal of Pain and Symptoms Management. He has also served as a reviewer for the Journal of Palliative Medicine, Annals of Internal Medicine, Journal of General Internal Medicine, Journal of Graduate Medical Education, and the Educational Clearinghouse for Internal Medicine.
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Dr. Lewis, Ms. Schechtman and Ms. Judy report no competing interests.
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For more <a href="https://www.pallimed.org/search/label/pain">Pallimed posts about pain><br />
For more <a href="https://www.pallimed.org/search/label/kollas">Pallimed posts by Dr. Kollas click here.</a>
<b>References</b>
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1. See https://www.youtube.com/watch?v=wb4ysxY0sUo at 0:46.
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2. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1
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3. Kollas C. Mandated PROP’s Disproportionate Influence on U.S. Opioid Policy: The Harms of Intended Consequences. Pallimed. May 2021. Available at: https://www.pallimed.org/2021/05/props-disproportionate-influence-on-us.html.
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4 Anson P. CDC Helped Draft CDC Opioid Guidelines. Pain News Network, September 21, 2015. https://www.painnewsnetwork.org/stories/2015/9/21/prop-helped-draft-cdc-opioid-guidelines.
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5. Von Korff M, Kolodny A, Deyo RA, Chou R. Long-Term Opioid Therapy Reconsidered. Ann Intern Med. 2011 September 6; 155(5): 325–328; See: https://www.acpjournals.org/doi/10.7326/0003-4819-155-5-201109060-00011?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed&.
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6. Ballantyne JC, Belgrade M, Carlisle R, Chou R, et al, PROP Petition to FDA; See: https://www.citizen.org/wp-content/uploads/migration/2048.pdf July 25, 2012
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7. See: https://www.cdc.gov/injury/pdfs/bsc/OWG_Terms-of-Ref_FINAL-7-6-2020r.pdf.
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8. See: https://www.asahq.org/-/media/sites/asahq/files/public/advocacy/federal-activities/regulatory-activities/pain-medicine/prop-letter-to-fda.pdf?la=en&hash=5427D6B9210FED65861AB50292CD97EB3907827C
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9. Franklin GM, Mai J, Wickizer T, Turner JA, Fulton-Kehoe D, Grant L. Opioid dosing trends and mortality in Washington State workers' compensation, 1996-2002. Am J Ind Med. 2005 Aug;48(2):91-9. doi: 10.1002/ajim.20191. PMID: 16032735.
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10. See http://www.agencymeddirectors.wa.gov/contact.asp.
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11. Interagency Guideline on Opioid Dosing for Chronic Non-Cancer Pain: An Educational Pilot to Improve Care and Safety with Opioid Treatment. Olympia, WA: Washington State Agency Medical Directors’ Group; March 2007. See http://www.agencymeddirectors.wa.gov/Files/Retired%20Opioid%20Guidelines.pdf.
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12. Mai J, Franklin G, Tauben D. Guideline for Prescribing Opioids to Treat Pain in Injured Workers. Phys Med Rehabil Clin N Am. 2015 Aug;26(3):453-65. See https://pubmed.ncbi.nlm.nih.gov/26231959/.
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13. See: https://www.supportprop.org/wp-content/uploads/2014/12/FDA_CDER_Response_to_Physicians_for_Responsible_Opioid_Prescribing_Partial_Petition_Approval_and_Denial.pdf.
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14. Berens MJ, Armstrong K. State plans emergency warning on risks of methadone. Seattle Times, December 21, 2011. See https://www.seattletimes.com/seattle-news/state-plans-emergency-warning-on-risks-of-methadone/.
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15. Fishman SM, Webster LR. Unintended harm from opioid prescribing guidelines. Pain Med. 2009 Mar;10(2):285-6. doi: 10.1111/j.1526-4637.2008.00553.x. Epub 2009 Jan 16. PMID: 19207238.
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16. Berens MJ, Armstrong K. State pushes prescription painkiller methadone, saving millions but costing lives. Seattle Times, December 10, 2011.
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17. OHSU Partners, Office of Clinical Integration and Evidence-Based Practice. Adult Safe Opioid Prescribing for Chronic, Non-End-of-Life Pain: Evidence Summary. August 9, 2017. See https://www.ohsu.edu/sites/default/files/2018-12/Opioid-Prescribing-Evidence-Summary_8-9-17.pdf. Last accessed 8/5/2021.
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18. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1external icon. See https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm.
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19. Chou R. Using evidence in pain practice: Part II: Interpreting and applying systematic reviews and clinical practice guidelines. Pain Med. 2008 Jul-Aug;9(5):531-41. doi: 10.1111/j.1526-4637.2008.00422_2.x. PMID: 18346061.
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23. Manchikanti L, Singh V, Helm S 2nd, Schultz DM, Datta S, Hirsch JA; American Society of Interventional Pain Physicians. An introduction to an evidence-based approach to interventional techniques in the management of chronic spinal pain. Pain Physician. 2009 Jul-Aug;12(4):E1-33. PMID: 19668280.
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26. Manchikanti L, Datta S, Derby R, Wolfer LR, Benyamin RM and Hirsch JA. A Critical Review of the American Pain Society Clinical Practice Guidelines for Interventional Techniques: Part 1. Diagnostic Interventions. Pain Physician. May/June 2010; 13:E141-174.
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28. Balshem H, Stevens A, Ansari M, Norris S, Kansagara D, Shamliyan T, Chou R, Chung M, Moher D, Kay Dickersin K. Finding Grey Literature Evidence and Assessing for Outcome and Analysis Reporting Biases When Comparing Medical Interventions: AHRQ and the Effective Health Care Program. In: In: Methods Guide for Effectiveness and Comparative Effectiveness Reviews [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008–. AHRQ Methods for Effective Health Care. 2013 Nov 18.
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20. Madara JL. Letter to Thomas Freiden, Director, Centers for Disease Control and Prevention. Re: Docket No. CDC-2015-0112; Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain. January 12, 2016. See https://searchlf.ama-assn.org/undefined/documentDownload?uri=%2Funstructured%2Fbinary%2Fletter%2FLETTERS%2Fcdc-opioid-guidelines-12jan2016.pdf.
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30. See https://www.slideshare.net/grouphealth/national-summit-on-opioid-safety.
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31. See https://www.slideshare.net/grouphealth/3-chou-opioid-summit-10-31-12.
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32. Palliadian Health, LLC. Palladian's Distinguished Clinicians Present at APTA's National CSM Convention in San Diego on 'Evidenced Informed Management of Chronic Low Back Pain Without Surgery.’ March 16, 2010. See https://www.prnewswire.com/news-releases/palladians-distinguished-clinicians- present-at-aptas-national-csm-convention-in-san-diego-on-evidenced-informed- management-of-chronic-low-back-pain-without-surgery-87763542.html.
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33. Chemodanova J. OHSU Awarded New Contract By The Agency For Healthcare Research And Quality. August 31, 2012. See https://stateofreform.com/news/oregon/2012/08/ohsu-awarded-new-contract-by-the-agency-for-healthcare-research-and-quality/.
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34. See https://www.cdcfoundation.org/our-story.
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35. See https://www.cdcfoundation.org/FAQ.
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36. See https://www.cdcfoundation.org/guiding-principles-partner-collaboration.
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37. See https://grouphealthfoundation.org/about-ghf/faqs/.
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38. See https://www.gih.org/grantmaker-focus/group-health-foundation/.
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39. See https://research.kpchr.org/
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40. See https://www.cdcfoundation.org/partner-list/foundations
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41. Anson P. Special Interest Groups Behind CDC Opioid Guidelines. Pain News Network, September 24. 2015. See http://www.painnewsnetwork.org/stories/2015/9/24/3xz1qq23yuilyeluz63kgwckplwh21.
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42. See https://govtribe.com/award/federal-contract-award/delivery-order-hhsa290201500009i-75q80119f32018.
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43. See https://effectivehealthcare.ahrq.gov/news/epc-contracts-awarded-december-2019.
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44. See https://www.ohsu.edu/evidence-based-practice-center/about.
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45. Chou R. Reviewing the Evidence on Outcomes of Opioid Tapers. Patient-Centered Approach to Chronic Opioid Management Conference, August 9, 2019. See http://www.agencymeddirectors.wa.gov/Files/COTS/4_Chou_Tapering%20Bree%20Collaborative%208.19_revised.pdf.
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46. Chou R, Ballantyne J, Lembke A. Rethinking Opioid Dose Tapering, Prescription Opioid Dependence, and Indications for Buprenorphine. Ann Intern Med. 2019 Sep 17;171(6):427-429. doi: 10.7326/M19-1488. Epub 2019 Aug 27. Erratum in: Ann Intern Med. 2019 Nov 5;171(9):684. PMID: 31450240.
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47. Correction: Rethinking Opioid Dose Tapering, Prescription Opioid Dependence, and Indications for Buprenorphine. Ann Intern Med. 2019 Nov 5;171(9):684. doi: 10.7326/L19-0595. Erratum for: Ann Intern Med. 2019 Aug 27;:null. PMID: 31683287.
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48. See https://rmed.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-1488&_ga=2.63881967.1144280822.1629813752-857333589.1616690931.
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49. Anson P. PROP President Discloses Conflicts of Interest, Pain News Network, November 12, 2019; https://www.painnewsnetwork.org/stories/2019/11/12/prop-president-discloses-conflicts).
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50. See https://govtribe.com/award/federal-contract-award/delivery-order-hhsa290201500009i-75q80119f32018.
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51. Anson P. PROP Linked to New Federal Opioid Study. Pain News Network, April 20, 2020. See https://www.painnewsnetwork.org/stories/2020/4/20/prop-linked-to-new-federal-opioid-study.
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52. Anson P. What is the CDC Trying to Hide? Pain News Network, April 16, 2020. See https://www.painnewsnetwork.org/stories/2020/4/15/what-is-cdc-trying-to-hide.
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53. See, for example, https://www.aapmr.org/members-publications/member-news/member-news-details/2021/06/08/ahrq-seeks-comments-regarding-two-pain-management-systematic-reviews.
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54. Formerly https://effectivehealthcare.ahrq.gov/products/integrated-pain-management/draft-research. As of August 24, 2021, this link is no longer active; please contact the authors for a PDF copy of this document.
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55. Kollas CD. Comments on the AHRQ Draft Report on Integrated Pain Management Programs. Submitted to AHRQ on June 7, 2020. PDF available from authors by request.
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56. Lawhern R. Comments to the July 16, 2021 Meeting of The US CDC National Center for Injury Prevention and Control Board of Scientific Counselors. Published on July 18, 2021. See https://www.linkedin.com/pulse/comments-july-16-2021-meeting-us-cdc-national-center-injury-lawhern/?trackingId=UDFjJsc3SYazTQYxt78y3g%3D%3D.
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57. Stewart TL. Let me get this straight… P3Alliance speaks on Chou’s COI during Public comment. July 16, 2021. See https://www.youtube.com/watch?v=DndVrnlc0y0.
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58. Anson P. CDC Advisory Panel Warns Revised Guideline Ignores Benefits of Opioids. Pain News Network, July 16, 2021. See https://www-painnewsnetwork-org.cdn.ampproject.org/c/s/www.painnewsnetwork.org/stories/2021/7/16/advisory-panel-warns-cdc-revised-opioid-guideline-ignores-risk-of-undertreating-pain.
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59. Kollas CD. Personal observation at 10 AM from the Roll Call of the CDC BSC-NPIPC Meeting on July 29, 2021.
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60. Darnall BD, et al (including Kollas CD). International Stakeholder Community of Pain Experts and Leaders Call for an Urgent Action on Forced Opioid Tapering. Pain Medicine, 2018; 0:1-4. See https://pubmed.ncbi.nlm.nih.gov/30496540/.
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61. See Resolution 235 at https://www.ama-assn.org/system/files/2018-11/i18-refcomm-b-annotated.pdf.
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62. Health Professionals for Patients in Pain (HP3), led by Alford DP (and including Kollas CD). Professionals Call on the CDC to Address Misapplication of its Guideline on Opioids for Chronic Pain through Public Clarification and Impact Evaluation. March 6, 2019. See https://healthprofessionalsforpatientsinpain.org/the-letter-1.
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63. Carlson RW, et al. Letter to Deborah Dowell, Chief Medical Officer, Opioid Response Coordinating Unit, CDC National Center for Injury Prevention and Control. February 13, 2019. See https://www.asco.org/sites/new-www.asco.org/files/content-files/advocacy-and-policy/documents/2019-NCCN-ASCO-ASH-Letter-CDC.pdf.
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64. Nicholson KM, Hoffman DE, Kollas CD. Overzealous use of the CDC’s opioid prescribing guideline is harming pain patients. Stat News, December 6, 2018. See https://www.statnews.com/2018/12/06/overzealous-use-cdc-opioid-prescribing-guideline/.
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65. FDA Drug Safety Communications. FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering. April 9, 2019. See https://www.fda.gov/media/122935/download.
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66. FDA Drug Safety Podcast. FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering. April 17, 2019. See https://www.fda.gov/drugs/fda-drug-safety-podcasts/fda-identifies-harm-reported-sudden-discontinuation-opioid-pain-medicines-and-requires-label-changes#:~:text=On%20April%209%2C%202019%20FDA,%2C%20psychological%20distress%2C%20and%20suicide.
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67. CDC Media Relations. CDC Advises Against Misapplication of the Guideline for Prescribing Opioids for Chronic Pain. Embargoed Until: Wednesday, April 24, 2019, 5 PM, EDT. See https://www.cdc.gov/media/releases/2019/s0424-advises-misapplication-guideline-prescribing-opioids.html.
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8. Mark TL, Parish W. Opioid medication discontinuation and risk of adverse opioid-related health care events. J Subst Abuse Treat. 2019 Aug;103:58-63. doi: 10.1016/j.jsat.2019.05.001. Epub 2019 May 5. PMID: 31079950.
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69. Perez HR, Buonora M, Cunningham CO, Heo M, Starrels JL. Opioid Taper Is Associated with Subsequent Termination of Care: a Retrospective Cohort Study. J Gen Intern Med. 2020 Jan;35(1):36-42. doi: 10.1007/s11606-019-05227-9. Epub 2019 Aug 19. PMID: 31428983; PMCID: PMC6957663.
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70. Oliva EM, Bowe T, Manhapra A, Kertesz S, Hah JM, Henderson P, Robinson A, Paik M, Sandbrink F, Gordon AJ, Trafton JA. Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation. BMJ. 2020 Mar 4;368:m283. doi: 10.1136/bmj.m283. PMID: 32131996; PMCID: PMC7249243.
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71. Kertesz SG, Manhapra A, Gordon AJ. Nonconsensual Dose Reduction Mandates are Not Justified Clinically or Ethically: An Analysis. J Law Med Ethics. 2020 Jun;48(2):259-267. doi: 10.1177/1073110520935337. PMID: 32631183; PMCID: PMC7938366.
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72. Agnoli A, Xing G, Tancredi DJ, Magnan E, Jerant A, Fenton JJ. Association of Dose Tapering With Overdose or Mental Health Crisis Among Patients Prescribed Long-term Opioids. JAMA. 2021 Aug 3;326(5):411-419. doi: 10.1001/jama.2021.11013. PMID: 34342618; PMCID: PMC8335575.
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73. Levy MH, Chwistek M, Mehta RS. Management of chronic pain in cancer survivors. Cancer J. 2008 Nov-Dec;14(6):401-9. doi: 10.1097/PPO.0b013e31818f5aa7. PMID: 19060605.
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74. Zhang H, Paice J, Portenoy R, Bruera E, Reid MC, Bao Y. Prescription Opioids Dispensed to Patients with Cancer with Bone Metastasis: 2011-2017. Oncologist. 2021 Jul 6. doi: 10.1002/onco.13898. Epub ahead of print. PMID: 34227175.
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75. Enzinger AC, Ghosh K, Keating NL, Cutler DM, Landrum MB, Wright AA. US Trends in Opioid Access Among Patients With Poor Prognosis Cancer Near the End-of-Life. J Clin Oncol. 2021 Jul 22:JCO2100476. doi: 10.1200/JCO.21.00476. Epub ahead of print. PMID: 34292766.
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76. Azizoddin DR, Knoerl R, Adam R, Kessler D, Tulsky JA, Edwards RR, Enzinger AC. Cancer pain self-management in the context of a national opioid epidemic: Experiences of patients with advanced cancer using opioids. Cancer. 2021 Sep 1;127(17):3239-3245. doi: 10.1002/cncr.33532. Epub 2021 Apr 27. PMID: 33905550; PMCID: PMC8355015.
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77. Lawhern R. Time for Heads to Roll at the US National Center for Injury Prevention and Control. American Council on Science and Health, August 26, 2021. See https://www.acsh.org/news/2021/08/26/time-heads-roll-us-national-center-injury-prevention-and-control-15759.
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78. See https://www.cdc.gov/opioids/data/analysis-resources.html.
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79. Mukkamala B. AMA Letter to Gwendolyn H. Cattledge, PhD, MSEH, Deputy Associate Director for Science, National Center for Injury Prevention and Control Centers for Disease Control and Prevention. July 22, 2021. See https://searchlf.ama-assn.org/letter/documentDownload?uri=%2Funstructured%2Fbinary%2Fletter%2FLETTERS%2F2021-7-22-Letter-to-Cattledge-re-CDC-BSC-Comments-final.pdf.
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80. Deutsch J. AMA backs update to CDC opioid prescribing guidelines. July 22, 2021. See https://www.ama-assn.org/press-center/press-releases/ama-backs-update-cdc-opioid-prescribing-guidelines?utm_source=twitter&utm_medium=social_ama&utm_term=5205422460&utm_campaign=Advocacy&utm_effort=FBB009.
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81. Dasgupta N, Wang Y, Jungjun B, Kinlaw A, Chidgey B, Cooper T, Delcher C. Inches, Centimeters and Yards: Overlooked Definition Choices Inhibit Interpretation of Morphine Equivalence. FDA Workshop, June 7-8, 2021. See https://www.fda.gov/media/150403/download.
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82. Anson P. Revised CDC Opioid Guideline Not Expected Until Late 2022. Pain News Network, July 9, 2021. See https://www.painnewsnetwork.org/stories/2021/7/9/revised-cdc-opioid-guideline-not-expected-until-late-2022.
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Pallimed Editorhttp://www.blogger.com/profile/11358791266969988517noreply@blogger.comtag:blogger.com,1999:blog-13495125.post-13594442439405679252021-07-14T13:00:00.012-05:002022-05-13T10:56:42.596-05:00How Spiritfarer Helped Me Through the Pandemic<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiY6wcqn9aJqSb-vevevMSiWTNAEuGxaiogCpazHpF7Zb-Awpr8gMsdbDIcJOB0FNRmB9cIgxKR9r13b8i5O3-6_xaK_VEvgxVyLElk6MXvTjMIEeIPEs4Or1-JiIVhB8Bu0793Qg/s1080/What+Remains+of+Edith+Finch.png" style="display: block; padding: 1em 0; text-align: center; clear: right; float: right;"><img alt="" border="0" width="320" data-original-height="1080" data-original-width="1080" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiY6wcqn9aJqSb-vevevMSiWTNAEuGxaiogCpazHpF7Zb-Awpr8gMsdbDIcJOB0FNRmB9cIgxKR9r13b8i5O3-6_xaK_VEvgxVyLElk6MXvTjMIEeIPEs4Or1-JiIVhB8Bu0793Qg/s320/What+Remains+of+Edith+Finch.png"/></a></div>
by Matthew Tyler (<a href="https://twitter.com/PalliDad" target="_blank">@PalliDad</a>)
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During what can only be described as a challenging year, I found Thunderlotus’s game <i><a href="https://thunderlotusgames.com/spiritfarer/" target="_blank">Spiritfarer</a></i> just in the nick of time. In this “cozy management game about dying,” you assume the role of a young woman named Stella who is charged with shuttling spirits to the gates of the afterlife. Unexpectedly, <i>Spiritfarer</i> served as both an escape from and means of processing my experience as a healthcare worker during the pandemic.
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From top to bottom, <i>Spiritfarer</i> exudes tranquility. The animations are bright and vibrant, and the music is soothing yet melancholy, invoking nostalgia for younger innocent days. With this backdrop, you spend your time in game managing the physical and emotional needs of your passengers. This entails gathering materials to upgrade your boat’s ability to reach more distant islands, constructing customized quarters to accommodate your growing roster of spirits, and cooking meals uniquely suited to each passenger’s preferences. I was especially delighted to learn I could hug passengers to boost their mood, though sometimes they will decline your offer - bonus points to the devs for promoting autonomy! Your efforts are reflected in the mood of each spirit - as it improves they share more about their lives. Ultimately, each story arc culminates in a heartfelt goodbye at the gate to the afterlife. For most of the spirits, at least. <div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiHOSTNBhY24KUzAubhxHCYb22HGEWKgJZsmvUT9ckjlO9B8VkMuLC67h2hT6jBH9K7lRvWRi_556knYDL4W1p3Hat38cizsLj74bFuf3CPqUebVl2ylx2nvAfI5TzpP1Exxo_Jag/s960/Spiritfarer_-_Gwen_Trailer.jpg" style="display: block; padding: 1em 0; text-align: center; clear: right; float: right;"><img alt="" border="0" width="320" data-original-height="540" data-original-width="960" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiHOSTNBhY24KUzAubhxHCYb22HGEWKgJZsmvUT9ckjlO9B8VkMuLC67h2hT6jBH9K7lRvWRi_556knYDL4W1p3Hat38cizsLj74bFuf3CPqUebVl2ylx2nvAfI5TzpP1Exxo_Jag/s320/Spiritfarer_-_Gwen_Trailer.jpg"/></a></div>
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One day, I was passing by the home of one of my favorite companions and saw the outside had been covered with flowers. My stomach lurched. Flowers only appeared after a spirit had passed through the gate, but how could this spirit already be gone? I hadn’t finished their storyline or said goodbye. What kind of closure was that?
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At that moment, I was flooded with memories of conversations where I had to tell someone that their loved one was dying from COVID. Since our hospital restricted visitors I never knew the faces of these family members, just their tortured voices as I broke the terrible news by phone. I did this over and over again every day for what felt like an eternity. There were no proper goodbyes for these families. There was no closure, because how could there be? The breakneck pace someone could go from healthy to dying was impossible to wrap their heads around. It was impossible to wrap my head around it too.
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In palliative care, we provide the medical knowledge necessary to help patients and families prepare for the future. We don’t talk about how that knowledge helps clinicians cope as well. Understanding how an illness progresses gives us mental schema to process the suffering to which we must bear witness. Yes, it’s awful to tell someone that the last line of cancer treatment didn’t work. But because we know the trajectory of metastatic cancer, it’s a conversation we mentally prepare to have at some point. There was no pre-existing narrative for COVID to emotionally brace ourselves for what was coming. So while I worked hard to navigate the devastation in the most optimal (or least terrible) way, I simultaneously resented the need. None of these people were supposed to be dying in the first place.
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<i>Spiritfarer</i> was a gentle nudge to loosen my grip on how I think the future is “supposed to” look. It reminded me that, scale aside, COVID does not hold a monopoly on unanticipated loss in this world. Nor does working adjacent to death afford any control over it. Though the lesson goes deeper than that. Even if we can’t control how or when someone’s story ends, we are still encouraged to play our role in it. We keep working to discover our companion’s favorite dish. We take a moment to embrace them when they are feeling low. We hold space to listen to their stories and what is most important to them. <i>Spiritfarer</i> drives home that the inability to control an outcome does not mean we can’t be active participants in the process. And ultimately, taking care of our community is how we shape our future. So we chart the best course we can, and let the open water take us.
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<i>Spiritfarer</i> is available to play on <a href="https://thunderlotusgames.com/spiritfarer/" target="_blank">PC (Steam), Xbox, Playstation and Nintendo Switch</a> systems.
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This post has a companion piece video narrated by Dr. Matt Tyler and hosted by Digital Doc Games (embedded below). Check out the <a href="https://www.youtube.com/c/DigitalDocGames/featured" target="_blank">Digital Doc Games YouTube channel</a> hosted by Dr. Amiad Fredman for videos on how video games have a huge power to have a positive impact on people's lives.
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<iframe width="560" height="315" src="https://www.youtube.com/embed/PRLvpkP_ANQ" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe>
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<iframe width="560" height="315" src="https://www.youtube-nocookie.com/embed/Xu4JHmcfrtw?controls=0" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe>
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For more <a href="https://www.pallimed.org/search/label/grief">Pallimed posts about grief.</a><br />
For more <a href="https://www.pallimed.org/search/label/covid">Pallimed posts about the experience with COVID-19.</a><br />
For more <a href="https://www.pallimed.org/search/label/tyler">Pallimed posts by Dr. Tyler click here.</a><br>
For more Pallimed posts on <a href="https://www.pallimed.org/search/label/video%20games" target="_blank">video games, click here.</a>
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<i>Matt Tyler is a palliative care doctor in Chicago. If he's not watching Cocomelon with his daughters, he is probably playing video games or making <a href="https://www.tiktok.com/@pallidad?_d=secCgYIASAHKAESMgowgwzhy7W1EsPN1Nh2pUMIddn1wvREg0j6yyBBJ76O8ZsGO7d80%2BzKIOda93yPpfIhGgA%3D&language=en&preview_pb=0&sec_user_id=MS4wLjABAAAA7-9ruKPrYrM3-EozY28i1X0XH8vFJVD5b15Cn1EapcyLD33SqG4qSHj2ttXXxqrW&share_item_id=6933597602348797189&share_link_id=BADC1D5C-E16A-43EF-BD9D-CD97D21F4C44&timestamp=1614356071&tt_from=twitter&u_code=dh23cf6kk0g28i&user_id=6927074031583200262&utm_campaign=client_share&utm_medium=ios&utm_source=twitter&source=h5_m" target="_blank">palliative care skits on TikTok.</a></i>
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<br><br>Pallimed Editorhttp://www.blogger.com/profile/11358791266969988517noreply@blogger.comtag:blogger.com,1999:blog-13495125.post-60888959337070864422021-06-14T15:01:00.001-05:002021-06-15T07:43:21.249-05:00Two Ways to Share your Palliative Care and Hospice Stories<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEipINWoZ02T2mN6J3nn0HxXnbMp4zUdfRzwSypUc0WGA7ZL2kuWELG7q8r8maiIxueE5wkk_25ME4Q2SLULumEFj9ZN6lI7QQ6tEq5bY0nhiUvmqUd1O8yzOHMZjGgYZGDO6PCGEA/s1600/E3m77Q9WUAUaq4m.jpg" style="display: block; padding: 1em 0; text-align: center; clear: right; float: right;"><img alt="" border="0" width="320" data-original-height="900" data-original-width="1600" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEipINWoZ02T2mN6J3nn0HxXnbMp4zUdfRzwSypUc0WGA7ZL2kuWELG7q8r8maiIxueE5wkk_25ME4Q2SLULumEFj9ZN6lI7QQ6tEq5bY0nhiUvmqUd1O8yzOHMZjGgYZGDO6PCGEA/s320/E3m77Q9WUAUaq4m.jpg"/></a></div>
by Christian Sinclair (<a href="https://twitter.com/ctsinclair" target="_blank">@ctsinclair</a>)
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This past few days, I came across two great opportunities that I wanted to share with a wider audience of hospice and palliative care clinicians.
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First is the podcast and radio show, Radiolab. I've always appreciated the nuance and simplicity the creators can bring to complex issues. They are looking for voice memos from people who work in end-of-life care. They are also looking for patients and families who have been impacted by this work. All you have to do is record a 60-seconds or less voice memo and email it to wnycradiolab@gmail.com. Make sure to include your name, city, and your position or connection to the work. For the official ask see the graphic on this post or <a href="https://twitter.com/Radiolab/status/1403359388983824391" target="_blank">this link on Twitter. </a> Share it with your teams!
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Second is a project by Dr. Kayla Sheehan, <a href="https://www.pallimed.org/2018/09/the-future-of-hospice-and-palliative.html" target="_blank">who has written for Pallimed before</a>. She is looking for hospice and palliative care physicians to share their origins stories on how they discovered this work. The answers are intended to be anonymous, so share as much as you feel comfortable. The link is here - <a href="https://dk9n3b78ef9.typeform.com/to/yCxDYZzR" target="_blank">https://dk9n3b78ef9.typeform.com/to/yCxDYZzR</a>
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For more <a href="https://www.pallimed.org/search/label/The%20profession">Pallimed posts about the profession, click here.</a><br />
For more <a href="https://www.pallimed.org/search/label/sinclair">Pallimed posts by Dr. Sinclair, click here.</a>
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<i>Christian Sinclair, MD, FAAHPM (@ctsinclair) is editor of Pallimed, a former hospice medical director and current outpatient palliative care physician at the University of Kansas Cancer Center. He has a experiential degree in Social Media and Health Care Marketing from the school of life. </i>
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Christian Sinclairhttp://www.blogger.com/profile/14685043408496367587noreply@blogger.comtag:blogger.com,1999:blog-13495125.post-67899060969151903452021-05-03T16:55:00.004-05:002021-05-06T16:34:10.222-05:00PROP’s Disproportionate Influence on U.S. Opioid Policy: The Harms of Intended Consequences<p style="margin-left: 40px"><i></i><br></p>
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by Chad Kollas, MD (<a href="https://twitter.com/ChadDKollas" target="_blank">@ChadDKollas</a>)
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<b>Introduction<br><br></b>
A recent study by the Centers for Disease Control (CDC) has captured the attention of the palliative care and chronic pain communities (1). Published on February 12, 2021, in Morbidity and Mortality Weekly Report (MMWR), it observed that the “age-adjusted overdose death rates involving synthetic opioids, psychostimulants, cocaine, heroin, and prescription opioids during 2013–2019” have increased a whopping 1,040% (1). Several critics have attributed this increase in overdose mortality to failed federal opioid policy, particularly the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain and their misapplication (2-4). This criticism has generated recent flurry of activity on social media by the anti-opioid advocacy group (5), Physicians for Responsible Opioid Prescribing (PROP). This commentary will explore how PROP’s flawed policy approach over the last decade has reduced legitimate access to opioid medications and contributed to harms from increases in overdose deaths in the United States (US).
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<b>PROP Appears on the Opioid Policy Scene<br><br></b>
In 2011, a group of internists, including Michael Van Korff, Andrew Kolodny and Roger Chou, co-authored an article that modern palliative care physicians would recognize as a “warning shot (6)” in the world of opioid policy (7). They announced the creation of Physicians for Responsible Opioid Prescribing (PROP), a “nonprofit organization with no pharmaceutical industry funding or ties,” that would “identify practical approaches to more cautious opioid prescribing in community practice (7).” They declared that “Guidelines for long-term opioid therapy should not be developed by the field of pain medicine alone. Rather, experts from general medicine, addiction medicine, and pain medicine should jointly reconsider how to increase the margin of safety (7).”
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<b>PROP Petition to the FDA on Opioid Labeling</b><br><br>
<center><i>The Petition is Filed</i><br></center>
In its first effort to influence national opioid policy, in July 2012, PROP submitted a Petition to the Food and Drug Administration (FDA) calling for a change in labeling of opioid analgesics (8). Signatories to the Petition included PROP President, Andrew Kolodny, PROP Vice-president, Michael Van Korff, and PROP Board Members, Jane Ballantyne, Roger Chou, Stephen Gelfand, and Gary Franklin, among other medical specialists, including American Society of Addiction Medicine (ASAM) President, Stu Gitlow (8). In its petition, PROP requested that the FDA to make three main changes to the labeling process for opioid analgesics:<br><br>
1) Strike the term “moderate” from the indication for non-cancer pain (the only clinical indication for using an opioid analgesic would be for severe cancer pain).<br>
2) Add a maximum daily dose of opioid analgesia, equivalent to 100 milligrams of oral morphine, for treatment of all non-cancer pain. <br>
3) Add a maximum duration of 90-days for continuous (daily) opioid analgesia use for non-cancer pain, after which opioid analgesia would be discontinued (8).<br>
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The FDA acknowledged receipt of the PROP Petition on July 26, 2012 (9), and it simultaneously received a letter of support for its petition on the same date, led by Congress member, Representative Mary Bono Mack from California (10).
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<center><i>The Backlash to the PROP Petition Begins<br></i></center>
This unity within the supporters of the petitioning group was short-lived. A representative from within the palliative care community alerted PROP FDA Petition signatory and American Society for Addiction Medicine (ASAM) President, Stu Gitlow, about substantial concerns from the pain management and palliative medicine communities about the potential reduced access to opioid therapy for many patients. In response to concerns that the PROP Petition might have a chilling effect on medically-legitimate opioid prescribing, ASAM released a statement by Gitlow clarifying its position that “the relabeling proposals [were] not intended, in any way, to limit a chronic pain patient’s access to clinically appropriate opioid pain therapy or to impinge upon a pain specialist’s ability to make individual decisions regarding the most effective therapy for their legitimate pain patient (11).”<br><br>
Several prominent pain management experts echoed important concerns about over-restricting patients’ medically legitimate access to opioid analgesics. Bob Twillman, a pain psychologist and Director of Policy and Advocacy for the American Academy of Pain Management (AAPM), pointed out that “the 90-day limit on use of opioid for [non-cancer pain was] arbitrarily chosen (12).” Because PROP’s Petition had criticized the use of long-term opioid therapy by citing a lack of evidence for opioids’ long-term effectiveness, Twillman also pointed out that “when considering opioid analgesics, FDA has used the standard of a 12-week trial of the medication[;] it has not required longer studies (12).” Similarly, co-chair the New York State Palliative Care Education and Training Council and palliative medicine physician, Russell Portenoy, wrote that in light of “the stunning disconnect between the label changes demanded in the petition and the ‘scientific basis’ presented to justify them, I am concerned that all of the signatories possess an incomplete understanding of opioid pharmacology and pain medicine, and as a result, may pursue regulatory changes that are not in the best interest of public health (13).”
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Other PROP critics included several medical professional organizations, like the American Society of Anesthesiologists (ASA), who challenged the clarity of a definition of cancer pain, asking rhetorically, “Who will decide whether the persistent pain, for example, of nerve damage incurred during an otherwise curative course of chemo- and radiation therapy is or is not cancer-related? (14).” Likewise, the American Academy of Pain Medicine (AAPM) stated “we have serious concerns about the petition and believe the rationale for the requested changes is seriously flawed, potentially harmful to patients with debilitating pain conditions for whom opioid therapy is indicated, and without substantive scientific foundation (15).”
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The American Pain Society (APS) cited similar concerns about the Petition’s “insufficient scientific evidence base to support [its] recommendations. Further, we are concerned that implementation of these labeling changes which would dictate indications, dosing and duration of opioid treatment will not accomplish the intended goals, but instead have unintended negative consequences for patients including but not limited to untreated pain and loss of access to individualized care (16).”
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<b>FDA Response to the PROP Petition</b><br><br>
On September 10, 2013, the FDA provided its response to the PROP Petition to change opioid labeling, which was granted in part and denied in part (17, 18). The FDA agreed with PROP that “more data are needed about the safety of long-term use of opioids,” and, to this end, they required “all new drug application (NDA) sponsors of ER/LA opioids to conduct postapproval studies and clinical trials… to assess certain known serious risks of ER/LA opioid use: misuse, abuse, hyperalgesia, addiction overdose and death (17).” Additionally, based on stakeholder input, the FDA determined that “safety labeling changes to the labeling of ER/LA opioid analgesics [were] needed to more effectively communicate to prescribers the serious risks associated with [those] drugs, and to more clearly describe the population in whom these drugs should be used be used in light of these serious risks – thus encouraging better prescribing, monitoring and patient counseling practices involving these drugs (17).” This included a new box warning to disclose risks from ER/LA opioid analgesics and the addition of the phrase, “indicated for the management of moderate to severe pain when a continuous, around-the-clock opioid analgesic is needed for an extended period of time (17).”
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Despite calling for these changes, the FDA disagreed with the most important requests from the PROP Petition. It rejected PROP’s separation of non-cancer pain from cancer pain, noting “a patient without cancer, like a patient with cancer, may suffer from chronic pain, and PROP has not provided scientific support for why labeling should recommend different treatment for such patients (17).” The FDA also rejected PROP’s call for a 100 mg/day maximum morphine equivalent (MME) daily dose limitation, noting “the scientific literature does not support establishing a maximum recommended dose of 100 mg MED (17).” Furthermore, the FDA noted that creating a maximum dose of 100 mg MED “could imply a superior opioid safety profile under that set threshold, when there is no data to support that conclusion (17).” Finally, the FDA determined that PROP’s request to limit the maximum duration of treatment with opioid analgesia to 90 days was “not supportable” based on the evidence presented in the Petition (17).
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<b>PROP’s Influences the CDC Guidelines</b><br><br>
<i><center>A New Federal Regulatory Target</center></i><br>
Although the FDA had rejected the most important changes which PROP had requested, based on a lack of scientific evidence, PROP publicly framed its FDA Opioid Labeling Petition as successful, then repeated its calls for a 100 mg/day MME (19). PROP had also explored other avenues to influence opioid policy and reduce opioid prescribing, reaching out for example to the Federation of State Medical Board (FSMB) to encourage it to make changes in its Revised Model Policy on the Appropriate Use of Opioid Analgesics in the Treatment of Pain (20). Ultimately, PROP identified a more accommodating regulatory agency than the FDA, the Centers for Disease Control and Prevention (CDC), which revealed via engagement webinars on September 16 and 17, 2015, that it had been drafting its own Opioid Prescribing Guidelines (21).
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<i><center>Another PROP Backlash</center></i><br>
In the days following these engagement webinars, critics expressed concerns about a lack of transparency in the drafting of the Opioid Prescribing Guidelines, because CDC had failed “to disclose what outside advisors it consulted with during the drafting of its controversial opioid prescribing guidelines for physicians (22).” Additional concerns involved an unusually short, 48-hour period for stakeholders to submit comments about the CDC Pain Guidelines upon their originally planned release in September 2015 (23). Moreover, revelations that at least five PROP Board Members - including PROP President Jane Ballantyne, PROP Vice-President Gary Franklin, PROP Founder Andrew Kolodny, PROP Board Member David Tauben and PROP Board Member David Juurlink – had served on the panels that helped develop the CDC Guidelines, stirred deeper concerns (23, 24). Jane Ballantyne MD, who had succeeded Andrew Kolodny as PROP President, served as the sole clinician from the pain management community to be included in the CDC Core Expert Group (25).
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Medical professional organizations joined in criticism of the CDC for a lack of transparency in its policy review process and the scarcity of pain management experts represented in the Core Expert Group (26). The American Medical Association (AMA) wrote that the “review process used to date by CDC, especially the public engagement webinars, [had] generated concern about lack of transparency (26),” and that the “process may have been better served by constructing a more balanced panel that included clinicians from various medical specialty and practice settings (26).” The Patient Quality of Life Coalition (PQLC), an advocacy group that included the American Academy of Hospice and Palliative Medicine (AAHPM), AAPM, the Center to Advance Palliative Care (CAPC), and the Hospice & Palliative Nurses association (HPNA), among others, wrote that “the Guideline in its current form is focused on curbing inappropriate [opioid] use, but seems devoid of empathy for patients who need legally‐prescribed opioid medications for relief from serious and long‐lasting pain that compromises their quality of life and independence (27).”
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Following this outcry for transparency and expanded clinical representation regarding content, the CDC announced a second, 30-day open-comment period on its proposed 2016 Pain Guidelines, effective December 14, 2015 (28, 29). This delayed the roll out of the CDC Pain Guidelines past its originally anticipated implementation in January 2016, and prompted PROP founder, Andrew Kolodny to complain, “Opening a docket will tack months on to the process [and also] increases the likelihood that the guideline may never be released. This is an enormous win for the opioid lobby (30)." Interestingly, Kolodny co-authored a subsequent article examining the role of pharma funding and support of the CDC Pain Guidelines, and found that “of the 158 organizations that commented on the CDC’s draft guidelines, approximately 80% supported them either with or without recommendations, including many that received funding from opioid manufacturers (31).”
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<b>The CDC Guidelines are Published, Despite Ongoing Concerns</b><br><br>
Notwithstanding PROP-founder Kolodny’s fears that the guidelines “may never be released (30),” the CDC Pain Guidelines were published via MMWR on March 18, 2016 (4). While most pain experts generally felt that the Pain Guidelines would be useful for those prescribing opioids in primary care settings, many expressed concerns that the Guidelines could be misapplied and affect a much broader group of patients than intended. For example, AMA board chair-elect, Patrice Harris, said that while the AMA shared the goal of reducing harm from opioid abuse, it remained concerned “about the evidence base informing some of the recommendations, conflicts with existing state laws and product labeling, and possible unintended consequences” including insurance coverage limitations for non-pharmacotherapeutic options for chronic pain (30). Similarly, Bob Twillman, executive director of the AAPM, said the CDC guidance “leaves much to be desired,” particularly regarding the limitations on dose, duration of treatment and arbitrary dosing threshold (32, 32). “Our concern is that, based on experience when states have implemented similar guidelines, some clinicians will interpret these ‘soft limits’ and thresholds as absolute ceiling doses, and that people with pain will suffer needlessly as a result,” Twillman said (32).
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On August 29, 2016, <i>a group of scientists from the CDC itself</i> expressed integrity concerns about the agency’s data and its “the current state of ethics,” noting that “[i]t appears that our mission is being influenced and shaped by outside parties and rogue interests (34),” without specifically identifying PROP as one of those forces. Calling themselves the “CDC Spider Group (CDC Scientists Preserving Integrity, Diligence and Ethics in Research),” they reached out to Carmen S. Villar, MSW Chief of Staff, Office of the Director for the CDC, plainly stating that CDC “data were clearly manipulated in irregular ways” for political purposes (34). In October 2016, an article echoed similar concerns regarding CDC’s manipulation of data in a variety of projects, again alleging that the CDC was being influenced by corporate and political interests in a way that compromised its data collection (34). Despite these warnings, the 2016 CDC Opioid Prescribing Guidelines were implemented as planned.
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<center><i>Unintended Harms and the Backlash Against Misapplication of the CDC Guidelines</i></center><br><br>
Just two years later, yet <i>another article</i> authored by CDC scientists was published in April 2018, again calling into question the methodology used by CDC to estimate opioid overdose deaths (35). The authors alleged that the CDC traditional method for calculating opioid overdose deaths <i>overestimated deaths due to prescription opioids</i> because the CDC failed to account for the emergence of illegally-manufactured fentanyl (IMF) as a cause of overdoses in its methodology (35). The authors proposed a method that would exclude IMF-related deaths for a more accurate estimate of total opioid overdose deaths (35). Using its traditional method, the CDC “estimated 32,445 prescription opioid–involved deaths occur[ing] in 2016.” Using these authors’ proposed “more conservative method, 17,087 prescription opioid–involved deaths occurred in 2016.” The concerned scientists concluded that “obtaining an accurate count of the true burden and differentiating between prescription and illicit opioid-involved deaths [was] essential to implement and evaluate public health and public safety efforts (35).”
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In addition to concerns about the accuracy of CDC’s overdose data, by 2018 it had become clear that misapplication of its Pain Guidelines had begun to contribute to deaths from “suicides within and outside of the Veterans Affairs Healthcare System in the United States” from forced or involuntary tapers off of opioid analgesics (36). Although the CDC had designed the Guidelines “as non-mandatory guidance for primary care physicians[,] legislators, pharmacy chains, insurers, and others [had] seized on certain parts of its dosage and supply recommendations and translated them into blanket limits in law[s] and mandatory policy (37).” These misapplications and unintended consequences prompted the passage of an AMA Resolution against ongoing, widespread misapplication of the CDC Pain Guidelines in November 2018 (38). Adopted by the AMA House of Delegates at its November 2018 Interim Meeting, the new AMA policy affirmed that: <br><br>
1) “Some patients with acute or chronic pain [may] benefit from taking opioid pain medications at doses greater than generally recommended in the CDC Guideline for Prescribing Opioids for Chronic Pain and that such care may be medically necessary and appropriate,” <br><br>
2) The “AMA advocate against misapplication of the CDC Guideline for Prescribing Opioids by pharmacists, health insurers, pharmacy benefit managers, legislatures, and governmental and private regulatory bodies in ways that prevent or limit patients’ medical access to opioid analgesia,” and, <br><br>
3) “No entity should use MME (morphine milligram equivalents) thresholds as anything more than guidance, and physicians should not be subject to professional discipline, loss of board certification, loss of clinical privileges, criminal prosecution, civil liability, or other penalties or practice limitations solely for prescribing opioids at a quantitative level above the MME thresholds found in the CDC Guideline for Prescribing Opioids (38).”<br><br>
In the months after adoption of this AMA policy change, more clinical professionals and medical societies would actively seek to reverse the harms of the CDC Pain Guidelines’ misapplication.
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In December 2018, a group of clinical leaders and international stakeholders in the pain management community signed an open letter calling for urgent action against forced tapering of opioids (36). On February 13, 2019, the National Comprehensive Cancer Network (NCCN), American Society of Clinical Oncology (ASCO) and the American Society of Hematology (ASH) sent a joint letter to Debra Dowell, Chef Medical Officer of the CDC Opioid Response Coordinating Unit, to follow up on a stakeholder meeting that was held on November 8, 2018, during which those professional organizations called for CDC “to address unintended implementation and reimbursement consequences that have been occurring in practice” because of the misapplication of CDC’s Pain Guidelines (39). On February 19, 2019, Dowell answered back in a letter that stated, “The Guideline is not intended to deny any patients who suffer from chronic pain from opioid therapy as an option for pain management (40).” She also wrote, “CDC encourages physicians to continue to use their clinical judgment and base treatment on what they know about their patients, including the use of opioids if determined to be the best course of treatment (40).” This response letter was embargoed for release until April 9, 2019 (40), to coincide with other anticipated press releases related to federal actions regarding misapplication of the Pain Guidelines (see below).
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Similarly, on March 6, 2019, a group identified as Health Professionals for Patients in Pain (HP3) called upon “the CDC to follow through with its commitment to evaluate the impact by consulting directly with a wide range of patients and caregivers, and by engaging epidemiologic experts to investigate reported suicides, increases in illicit opioid use and, to the extent possible, expressions of suicidal ideation following involuntary opioid taper or discontinuation (41).” HP3 also urged “the CDC to issue a bold clarification about the 2016 Guideline – what it says and what it does not say, particularly on the matters of opioid taper and discontinuation (41).” The CDC responded on April 10, 2019, noting that “the Guideline does not endorse mandated or abrupt dose reduction or discontinuation, as these actions can result in patient harm (42).”
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<b>FDA Warning and CDC Clarification About the Pain Guidelines</b><br><br>
<center><i>FDA Warning Against Rapid Tapers</i></center><br>
One day prior to the CDC response letter to HP3 (42), on April 9, 2019, the FDA posted a safety announcement warning against sudden discontinuation of opioid pain medications (43). In the announcement, the FDA noted that it had “received reports of serious harm in patients who are physically dependent on opioid pain medicines suddenly having these medicines discontinued or the dose rapidly decreased. These include serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide (43).” This information was also released via a special FDA podcast on 4/17/2019 (44). <br><br>
<i><center>CDC Warns Against Misapplication of its Pain Guidelines; PROP Gets Defensive</center></i><br><br>
In view of the embargo for release of the CDC response to the NCCN-ASCO-ASH, which occurred on April 9, 2019 (40), and the CDC response to HP3 (42) on April 10, 2019, it seems likely that the FDA and CDC coordinated their communications to response to the Pain Guideline backlash. CDC then released another embargoed statement on April 24, 2019, in which it advised against the misapplication of its Guideline for Prescribing Opioids for Chronic Pain (45). More explicitly, CDC sought to raise “awareness about the following issues that could put patients at risk: <br><br>
- Misapplication of recommendations to populations outside of the Guideline’s scope. <br>
- Misapplication of the Guideline’s dosage recommendation that results in hard limits or ‘cutting off’ opioids. <br>
- The Guideline does not support abrupt tapering or sudden discontinuation of opioids. <br>
- Misapplication of the Guideline’s dosage recommendation to patients receiving or starting medication-assisted treatment for opioid use disorder (45).”<br><br>
On the heels of this media release, the CDC referenced a companion article published in New England Journal of Medicine (NEJM), co-authored by PROP member and CDC Core Group member, Roger Chou, which was available online on April 24, 2019, and in print on June 13, 2019 (46). Those authors also admitted that “some policies and practices purportedly derived from the guideline have in fact been inconsistent with, and often go beyond, its recommendations (46).” But in contrast to the contrite note struck by the CDC media release, the NEJM article vigorously defended the Pain Guidelines, noting that “the medical and health policy communities [had] largely embraced its recommendations” and that “the guideline was rated as high quality by the ECRI Guidelines Trust Scorecard (46).” The NEJM article also dismissed allegations about the lack of transparency in the Guideline creation, noting that the CDC had “engaged clinicians, health systems leaders, payers, and other decision makers in discussions of the guideline’s intent and provided clinical tools, including a mobile application and training, to facilitate appropriate implementation (46).” Notably, the article ended with this disclaimer: “The views expressed in this article are those of the authors and do not necessarily represent the official position of the Centers
for Disease Control and Prevention (46).”
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<b>Undeclared Conflicts of Interest</b><br><br>
Less than a month after the printed publication of the Chou’s NEJM article defending the Pain Guidelines, the US Department of Justice (DOJ) announced obtaining a record-setting $1.4 billion settlement against Reckitt Benckiser, the manufacturer of Suboxone, an opioid addiction treatment drug (47). For years, critics had alleged financial connections between PROP members and Reckitt Benckiser, with suspicions driven by comments by PROP’s Kolodny, who in 2005 - when asked about his financial relationship with the company - replied, “They are not a pharmaceutical company. They make Lysol (48)." In 2015, Reckitt Benckiser had spun off its Suboxone manufacturing to a subsidiary that it named Indivior (49), more commonly identified as its manufacturer currently. Additionally, in recorded testimony during government hearings, Kolodny had encouraged the use of Suboxone as a measure to combat the opioid crisis. In 2011, at a New York State Senate Hearing, then-PROP President Kolodny testified, ““If we want to see a decline in overdose deaths, you have to [sic] provide effective treatment for people who are opioid-addicted. And for this epidemic, that’s probably going to mean buprenorphine (50).” Likewise, during a US Senate Hearing in 2018, Kolodny testified, “The first-line treatment for opioid addiction is buprenorphine, also called ‘’Suboxone.’ Access to this treatment is not sufficient (51).”
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Testimony from hearings encouraging the use of Suboxone and deflective comments, like Kolodny’s dismissal about his relationship with Reckitt Benckiser, were less suspicious as betraying conflicting interests before it was revealed that PROP members failed to disclose relevant conflicts of interest when authoring several articles printed in medical journals. Kolodny failed to disclose conflicts of interest pursuant to his executive directorship of PROP and provision of expert witness testimony in malpractice cases involving opioids when he published two articles in the Journal of the American Medical Association (JAMA) in October 2017 and April 2018 (52). Similarly, PROP President, Jane Ballantyne, failed to disclose her affiliation with PROP in an “Ideas and Opinions” article, co-authored with PROP members, Anna Lembke and Roger Chau, in Annals of Internal Medicine in 2019 (53, 54). Moreover, PROP’s Mark Sullivan failed to declare a conflict of interest regarding his work on a opioid tapering device, which occurred during his participation in the drafting of the CDC Pain Guidelines, until he was participating in a CDC-sponsored Clinical Outreach and Community Activity, after the Guidelines’ publication (55). More recently, the British Medical Journal (BMJ) updated a “Rapid Response” that accused the AMA of a pharmaceutical industry bias when creating opioid policy, written by several members of PROP, when it was revealed that one of the co-authors, PROP’s Sullivan, did not disclose his competing interest related to his work as an expert witness in cases in Maryland and Missouri (56).
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Despite their collective tendency to under-report relevant conflicts of interest in publications, PROP members continued to place themselves successfully in key positions to enhance their ability to shape opioid policy. In early April 2020, the Agency for Healthcare Research and Quality (AHRQ) disclosed for the first time the identity of the authors of the controversial report, “Opioid Treatment for Chronic Pain,” which had concluded “opioids were no more effective in treating pain than nonopioid medication, and that long-term use of opioids increases the risk of abuse, addiction and overdose, especially at high doses (57).” The lead author of that report was revealed to be Roger Chou, a PROP member who has been described as “a vocal critic of opioid prescribing for years (58).” This revelation was especially concerning at the time, because CDC had announced its plans to review and possibly revise the 2016 CDC Pain Guidelines, which were co-authored by Chou, and because the AHRQ study had reaffirmed many of CDC’s still-disputed conclusions about opioid therapy (58).
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<b>CDC Begins a Reassessment of the 2016 CDC Pain Guidelines</b><br><br>
<center><i>Open Docket for Comments</i></center><br>
On April 17, 2020, the CDC announced “the opening of a docket to obtain comment concerning perspectives on and experiences with pain and pain management, including but not limited to the benefits and harms of opioid use, from patients with acute or chronic pain, patients' family members and/or caregivers, and health care providers who care for patients with pain or conditions that can complicate pain management (59).” Eventually, it received 5,392 comments from patients, physicians, medical organizations, and other stakeholders with feedback about its 2016 Pain Guidelines (60).
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The AAHPM did not mince words when commenting about its concerns of misapplication of the CDC Pain Guidelines: “The 2016 Guideline has been broadly misapplied, with devasting effect on patients and prescribers. Forced tapering of patients’ opioid prescriptions has been incentivized and/or mandated, violating ethical and evidentiary norms of medical practice. This has resulted in many patients’ medical deterioration, loss of care relationships, turning to illicit substances/alcohol, and suicidality. Swapping products and formulations to reduce opioid prescriptions where not medically necessary has also led to medical errors. At the same time, prescribers have faced professional discipline, loss of board certification, loss of clinical privileges, criminal prosecution, civil liability, or other penalties or practice limitations solely for prescribing opioids at a quantitative level above the morphine milligram equivalent (MME) thresholds included in the CDC Guideline (61).”
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The AMA echoed these concerns, writing “It is clear that the CDC Guideline has harmed many patients—so much so that in 2019, the CDC authors and HHS issued long-overdue, but greatly appreciated, clarifications that states should not use the CDC Guideline to implement an arbitrary threshold (Italics mine, 62). It also noted that “the CDC Guideline has been misapplied as a hard policy threshold by states, health plans, pharmacy chains, and PBMs,” and that “these policies, moreover, have not withstood any meaningful evaluation or data analysis as to whether they have improved pain care or reduced opioid-related harms (62). There also are no data to suggest that payers have increased access to non-opioid pain care options. If one of the goals of the CDC Guideline was to increase access to non-opioid pain care, that has not been realized (62). Rather, there is evidence that payers continue to erect and support barriers to non-opioid pain care (62).” The AMA urged the CDC to rescind policies employed by “many health insurers, pharmacy chains, and PBMs” based on the concept of a hard MME threshold to avoid “harms done to patients as a result of inappropriate tapering or denials of care (62, 63).
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In its comments, PROP conceded that reduced opioid prescribing was associated with downward trends in “prescription opioid related morbidity and mortality (64),” but did not acknowledge a concomitant, upward trend in total opioid-related morbidity and mortality from illicit drug, including illegally manufactured fentanyl. They further argued, “For some patients, continued opioid use is necessary not because it effectively manages the pain that prompted opioid prescribing initially, but because continued use averts the negative effects of opioid discontinuation (64),” a claim advocates for patients with chronic pain have labeled as a gaslighting strategy (65). Furthermore, as discussed later in the article, PROP also incorrectly predicted, “The downward trends in new starts of chronic opioid treatment achieved by the 2016 guideline should be seen as a positive development that will encourage people to find alternative means of controlling chronic pain, which though harder to employ than the prescription pad, will ultimately result in better outcomes and less distress (65).”
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<center><i>The BSC/NCIPC Workgroup</i></center><br>
On July 6, 2020, the CDC announced the formation of a new Opioid Workgroup and the Board of Scientific Counselors, National Center for Injury Prevention and Control Centers for Disease Control and Prevention (The BSC/NCIPC Workgroup), which would “review the Opioid Workgroup’s report, discuss, deliberate, and provide advice and recommendations for CDC to consider as part of the potential update and/or expansion of the Guideline. The updated and/or expanded Guideline is anticipated to be released in 2022 (66).” This announcement was followed by the release of a PowerPoint Presentation entitled, “Update on the BSC/NCIPC Workgroup,” on July 22, 2020, which elaborated on the process of choosing the new Opioid Workgroup (67). An additional update from October 13, 2020, identified the membership of the Opioid Workgroup – NCIPC BSC Committee Members (68). The updated and/or expanded Pain Guideline was anticipated to be released in 2022 (66), but that timeframe was projected before the full impact of the COVID-19 Pandemic.
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<b>Increases in Overdose Deaths and CDC Data Flaws</b>
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<center><i>The February 2021 MMWR Report</i></center>
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While the world anxiously awaited word on any new or revised CDC Pain Guidelines, on February 12, 2021, the MMWR Report (1) mentioned at the top of this commentary quickly captured the attention of those already hungry for news from the CDC, including patients with chronic pain and clinicians who manage that pain. In the setting of a 1,040% increase in “age-adjusted overdose death rates involving synthetic opioids, psychostimulants, cocaine, heroin, and prescription opioids during 2013–2019 (1),” it seemed prudent to critically question PROP’s assertion that “The downward trends in new starts of chronic opioid treatment achieved by the 2016 guideline should be seen as a positive development that will encourage people to find alternative means of controlling chronic pain, which though harder to employ than the prescription pad, will ultimately result in better outcomes and less distress (64).”
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On February 16, 2021, in what felt like an effort to draw attention away from the stark reality of the MMWR Report, PROP wrote a letter to AMA President, Susan R. Bailey, regarding “AMA’s Opposition to Dose & Duration Guidance for Opioid Prescribing (69),” based on AMA’s comments to Dr. Deborah Dowell in the CDC Open Docket (61). PROP concomitantly published this letter to the AMA as a “Rapid Response” to an article entitled, “UK recommendations on opioid stewardship (70, 71).” The letter alleged that AMA Opioid Policy was inappropriately influenced by donations from the pharmaceutical industry (69, 70). AMA President, Susan Bailey, quickly responded back to PROP, in a letter dated February 19, 2021, saying “With respect to the issue you raise in your letter, it might be helpful to point out that the CDC authors of the 2016 CDC Guideline themselves have recognized it has been misapplied (Italics mine; 72, 73).” Additionally, Bailey pointed out, “When policies or organizations focus only on the restriction of a legitimate pharmacologic option to help patients with pain, they miss the chance to address the complexity of policies needed to truly help patients with pain. That misguided focus also has led to harmful stigmatization and other stressors. That is why the AMA provided comprehensive recommendations on the 2016 CDC Guideline and why we continue to advocate for policies that support comprehensive, multidisciplinary, multimodal pain care, including opioid therapy when appropriate. If you choose to cite the AMA’s policies in the future, we encourage you to cite them in their entirety to ensure accurate context (72),” and Bailey provided the link for the AMA’s comments to Deborah Dowell to guide PROP when referencing AMA policy in the future (62).
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<i><center>Inaccurate CDC Data on Opioid Deaths</center></i>
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Just a few weeks later, PROP’s troubles worsened, with the publication of an article by John Peppin and John J. Coleman in Pain Therapy (74) that detailed fundamental methodological shortcomings in CDC’s data on prescription overdose deaths (35). The authors held that “CDC erroneously reported prescription opioid overdose deaths in 2016 and for more than a decade before (74)” in a way that overestimated overdose deaths due to prescribed opioids. They further assert that “the CDC ignored the problem until 2016 data showed serious inconsistencies with other, more reputable, data for prescribing volumes of opioids (74).” Furthermore, in “2018, the U.S. Congress mandated the CDC to ‘’modernize’’ its system for reporting drug overdose deaths but this has not yet occurred (74).” They concluded: “For more than a decade, millions of Americans were misled into believing that—as a White House report once characterized it— ‘opiate overdoses, once almost always due to heroin use, are now increasingly due to abuse of prescription painkillers.’ Little did they know or suspect that the CDC’s coding of prescription painkillers included non-prescribed illicitly manufactured fentanyl and fentanyl analogs and non-prescribed methadone administered or dispensed to patients being treated for opioid use disorder (74).”
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This report again exposed PROP’s and CDC’s false narrative that overprescribing of opioid analgesics had driven the US overdose crisis (74). In a predictable response, Andrew Kolodny reacted quickly to soften the crushing blow and establish some semblance of plausible deniability for PROP’s culpability. On March 22, 2021, Kolodny produced a webinar during which he “refuted” several alleged “myths and false narratives” about the opioid crisis (75). This presentation was swiftly characterized as “a rambling dialogue by Kolodny that gaslighted pain sufferers, doctors, patient advocates and anyone else critical of the CDC guideline (76).” For example, in a clear example of a Straw Man Argument (77), Kolodny alleged a myth that the “CDC Guideline forced millions of patients off opioids resulting in an epidemic of suicides (75),” when in fact both the CDC and FDA had publicly acknowledged the potential harms of forced tapers, acknowledging that the extent of the harm was not yet known (Italics mine, 42-45). In response to legitimate concerns about harms from polices influenced by PROP’s advocacy, one of its individual members had responded with gaslighting (75), informal fallacies (77) and deflection, aimed apparently at creating plausible deniability for their contribution to those harms.
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<b>Conclusion</b>
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Despite being turned back from an effort to bluntly reduce opioid prescribing by the FDA in 2013 based on a lack of scientific evidence for its position (17,18), PROP has had a disproportionate effect on opioid policy in the Untied States for almost a decade. PROP found a willing federal regulatory partner in the CDC, and while PROP may not have “secretly written” the 2016 CDC Pain Guidelines (75), they certainly enjoyed disproportionate representation on CDC’s review panels and Core Expert Group (23-25) in a process that lacked transparency (22, 23, 26, 27). When the CDC admitted that its Pain Guideline had been widely misapplied (40) and joined the FDA in a call against forced opioid tapers (42, 43, 45), PROP doubled down on its rhetoric (46), dismissing legitimate concerns about potential harms in a performative manner (75) that encouraged their ongoing misapplication, while assailing PROP’s critics (76, 77). All of this has occurred as PROP members have repeatedly concealed relevant conflicts of interest, including key conflicts that should have been disclosed during the process of drafting the CDC Pain Guidelines (48-54).
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Given this, at a minimum, PROP should no longer enjoy a prominent role in guiding future opioid policy in the United States. This is a particularly urgent concern, as Roger Chou has been linked to authorship of CDC’s New Pain Guidelines, which have not yet been released to the public (78). Chou’s involvement in yet another set of Guidelines and CDC’s recurrent lack of transparency (79) in identifying the new Guidelines’ authors should alarm all advocates who support access to pain medications for all patients with a medically legitimate indication for opioid therapy.
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Beyond limiting PROP’s role in developing future, potentially harmful opioid policy, a reasonable individual would be justified in wondering to what extent PROP bears culpability for the harms that arose from misapplications of the 2016 CDC Pain Guidelines. In our country, civil suits – like class action lawsuits, for example – only require a preponderance of the evidence – that is something is “more likely than not” - as the burden of proof for liability. It is more likely than not that PROP’s efforts to affect opioid policy helped shape the CDC Guidelines, which CDC has admitted were misapplied harmfully (40). It is also more likely than not that PROP’s performative advocacy efforts contributed to misapplication of the CDC Guidelines. And it is more likely than not that widespread misapplication of the CDC Guidelines resulted in harms with attendant civil liability. This would expose PROP to civil liability with a potentially enormous settlement if a class action suit were to arise from those harmed by the misapplication of the CDC Guidelines. Perhaps that is why PROP member, Andrew Kolodny, and others have worked so hard recently to create plausibly deniability (75) in the wake of the damaging February 12, 2021, MMWR Report (2).
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For more <a href="https://www.pallimed.org/search/label/opioids">Pallimed posts about opioids.</a><br />
For more <a href="https://www.pallimed.org/search/label/pain">Pallimed posts about pain and pain control.</a><br />
For more <a href="https://www.pallimed.org/search/label/kollas">Pallimed posts by Dr. Kollas click here.</a>
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<i>Dr. Kollas is board certified in internal medicine and provides pallative and supportive care in Orlando, FL.. He first wrote about his personal experiences with chronic illness and pain in a 1997 article in the “On Being a Patient” series in Annals of Internal Medicine. <a href="https://twitter.com/ChadDKollas?ref_src=twsrc%5Egoogle%7Ctwcamp%5Eserp%7Ctwgr%5Eauthor" target="_blank">You can find him on Twitter at @ChadDKollas</a>.</i>
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To cite this article: Kollas C. Mandated PROP’s Disproportionate Influence on U.S. Opioid Policy: The Harms of Intended Consequences. Pallimed. May 2021. Available at: https://www.pallimed.org/2021/05/props-disproportionate-influence-on-us.html
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<b>Correction 5/4/2021:</b> A date was incorrectly included in the original article as "April 9, 2021," which was incorrect. It was changed to the correct date of "April 9, 2019."
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Addition 5/6/2021: A Twitter user was able to find the PDF link to Reference number 40. The reference was updated with this link.
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<b>Conflict of Interest (submitted upon publication, added here 5/4): </b>Dr. Kollas had submitted a Conflict of Interest statement when submitting this article for publication. It was not originally included in error in the original article here due to editor error. You can find the conflict of interest statement here - https://twitter.com/ChadDKollas/status/1389616181762478080. We have a copy of the COI statement, if this link ever is removed or in error.
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<b>References</b>
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1. Mattson CL, et al. MMWR, February 12, 2021. 70(6):202-7 (or see https://www.cdc.gov/mmwr/volumes/70/wr/pdfs/mm7006-H.pdf).
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2. See https://twitter.com/BethDarnall/status/1366901343642742784.
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3. See https://twitter.com/ChadDKollas/status/1365661703191560192.
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4. See the CDC Pain Guidelines at https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm.
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5. See https://twitter.com/supportprop/status/1362043581544947712.
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6. Old, JL. Fam Pract Manag. 2011 Nov-Dec;18(6):31-35 (or see https://www.aafp.org/fpm/2011/1100/p31.html.
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7. Von Korff M, et al. Ann Intern Med. 2011 September 6; 155(5): 325–328; See https://www.acpjournals.org/doi/10.7326/0003-4819-155-5-201109060-00011?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed&.
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8. PROP Petition to FDA, 2012, See https://www.citizen.org/wp-content/uploads/migration/2048.pdf.
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9. See https://www.regulations.gov/document/FDA-2012-P-0818-0002.
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10. See https://www.joepaduda.com/2012/08/14/responsible_opi/.
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11. See food-and-drug-administration-follow-up-letter-to-relabeling-petition-clarification-of-asam-position-nbsp-september-13-2012.pdf.
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12. Originally posted at http://updates.pain-topics.org/2012/08/group-petitions-fda-to-change-opioid.html, but that link is not operational; the article is currently referenced at https://painpolicy.wordpress.com/2012/08/03/why-the-fda-shouldnt-change-the-labeling-of-opioid-analgesics/.
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13. Portenoy RK. Letter to Nirav R. Shah, MD, MPH, Commissioner, New York State Department of Health. August 16, 2012. (PDF copy available on request from this article’s author).
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14. See https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwi8i4imqMzvAhU_TDABHQS7Cc4QFjAAegQIBRAD&url=https%3A%2F%2Fwww.asahq.org%2F-%2Fmedia%2Fsites%2Fasahq%2Ffiles%2Fpublic%2Fadvocacy%2Ffederal-activities%2Fregulatory-activities%2Fpain-medicine%2Fasa-letter-fda-prop-8-22-12.pdf%3Fla%3Den%26hash%3D09DC35AB25C0C8F30807578C2038EA0244B7D7C9&usg=AOvVaw1-eZoU2_-k4xbDsC4EYdjT.
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15. Grabois M. Letter to Dockets Management Branch, Food and Drug Administration. August 12, 2012. (PDF copy available on request from this article’s author).
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16. See https://www.acttion.org/static/docs/aps_letter.pdf; referenced at https://www.acttion.org/news/november-26-2013-american-pain-society-letter-to-fda-commissioner-hamburg-about-immpact-and-acttion).
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17. See https://www.supportprop.org/wp-content/uploads/2014/12/FDA_CDER_Response_to_Physicians_for_Responsible_Opioid_Prescribing_Partial_Petition_Approval_and_Denial.pdf.
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18. See http://www.fdalawblog.net/2013/09/fda-grants-prop-petition-in-part-proposes-new-labeling-and-requires-post-marketing-studies-for-erla/.
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19. See http://www.supportprop.org/wp-content/uploads/2014/01/PROP_OpioidPrescribing.pdf.
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20. See http://www.supportprop.org/wp-content/uploads/2014/12/PA_3_29_13_FSMB.pdf.
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21. See https://www.cdc.gov/injury/pdfs/fundedprograms/Response_to_Constituent_Comment_CDC_Prescribing_Guideline.pdf.
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22. Anson P. CDC Maintains Secrecy Over Opioid Guidelines. Pain News Network, September 18. 2015. See https://www.painnewsnetwork.org/stories/2015/9/18/cdc-maintains-secrecy-over-opioid-guidelines.
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23. Anson P. Chronic Pain Groups Blast CDC for Opioid Guidelines. Pain News Network, September 22, 2015. See https://www.painnewsnetwork.org/stories/2015/9/22/chronic-pain-groups-blast-cdc-for-opioid-guidelines.
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24. Anson P. Special Interest Groups Behind CDC Opioid Guidelines. Pain News Network, September 24, 2015. See https://www.painnewsnetwork.org/stories/2015/9/24/3xz1qq23yuilyeluz63kgwckplwh21.
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25. Anson P. PROP Helped Draft the CDC Guidelines. Pain News Network, September 21, 2015. See https://www.painnewsnetwork.org/stories/2015/9/21/prop-helped-draft-cdc-opioid-guidelines.
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26. Madara JL. Letter to Thomas Freiden, Director, Centers for Disease Control and Prevention. October 1, 2015. (PDF copy available on request from article’s author).
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27. Patient Quality of Life Coalition. Letter to The Honorable Lamar Alexander, Chairman, Committee of Health, Education, Labor and Pensions, United States Senate. November 13, 2015. (PDF copy available on request from this article’s author).
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28. See https://www.federalregister.gov/documents/2015/12/14/2015-31375/proposed-2016-guideline-for-prescribing-opioids-for-chronic-pain.
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29. Samp R. CDC Bows To Demands For Transparency And Public Input On Draft Opioid-Prescribing Guidelines. Forbes, December 15, 2015. See http://www.forbes.com/sites/wlf/2015/12/15/cdc-bows-to-demands-for-transparency-and-public-input-on-draft-opioid-prescribing-guidelines/#36c587e1122a.
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30. Norman B. POLITICO Pro: CDC opens opioid prescription guidelines to public comment. Politico, December 11, 2015. (PDF copy available on request from this article’s author).
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31. Lin DH, et al. Financial Conflicts of Interest and the Centers for Disease Control and Prevention’s 2016 Guideline for Prescribing Opioids for Chronic Pain. JAMA Internal Medicine, March 2017; 177(3):427-8.
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32. Fiore K. CDC Comes Down Hard on Opioids for Chronic Pain — Urges physicians not to use opioids first-line for chronic pain. MedPage Today, March 15, 2016. See https://www.medpagetoday.com/publichealthpolicy/publichealth/56745.
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32. See http://blog.aapainmanage.org/academys-response-center-disease-controls-guideline-prescribing-opioids-chronic-pain/.
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33. See https://usrtk.org/wp-content/uploads/2016/10/CDC_SPIDER_Letter-1.pdf.
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34. Gillam C. The CDC is being influenced by corporate and political interests. The Hill, October 17, 2016. See https://thehill.com/blogs/pundits-blog/healthcare/301432-the-cdc-is-being-being-influenced-by-corporate-and-political .
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35. Seth P, et al. Quantifying the Epidemic of Prescription Opioid Overdose Deaths. AJPH, April 2018; 108(4):500-2. See https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5844400/pdf/AJPH.2017.304265.pdf.
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36. Darnall BD, et al (including Kollas CD). International Stakeholder Community of Pain Experts and Leaders Call for an Urgent Action on Forced Opioid Tapering. Pain Medicine, 2018; 0:1-4. See https://pubmed.ncbi.nlm.nih.gov/30496540/.
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37. Nicholson KM, Hoffman DE, Kollas CD. Overzealous use of the CDC’s opioid prescribing guideline is harming pain patients. Stat News, December 6, 2018. See https://www.statnews.com/2018/12/06/overzealous-use-cdc-opioid-prescribing-guideline/.
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38. See Resolution 235 at https://www.ama-assn.org/system/files/2018-11/i18-refcomm-b-annotated.pdf.
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39. Carlson RW, et al. Letter to Deborah Dowell, Chief Medical Officer, Opioid Response Coordinating Unit, CDC National Center for Injury Prevention and Control. February 13, 2019. See https://www.asco.org/sites/new-www.asco.org/files/content-files/advocacy-and-policy/documents/2019-NCCN-ASCO-ASH-Letter-CDC.pdf.
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40. Dowell D. Centers for Disease Control and Prevention. Letter to NCCN, ASCO, ASH, February 28, 2019. https://www.asco.org/sites/new-www.asco.org/files/content-files/advocacy-and-policy/documents/2019-CDC-Opioid-Guideline-Clarification-Letter-to-ASCO-ASH-NCCN.pdf
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41. Health Professionals for Patients in Pain (HP3), led by Alford DP (and including Kollas CD). Professionals Call on the CDC to Address Misapplication of its Guideline on Opioids for Chronic Pain through Public Clarification and Impact Evaluation. March 6, 2019. See https://healthprofessionalsforpatientsinpain.org/the-letter-1.
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42. Centers for Disease Control and Prevention. Letter to Daniel P. Alford MD MPH, Professor of Medicine, Brown University Medical Campus. April 10, 2019. (PDF copy available on request from this article’s author).
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43. FDA Drug Safety Communications. FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering. April 9, 2019. See https://www.fda.gov/media/122935/download.
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44. FDA Drug Safety Podcast. FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering. April 17, 2019. See https://www.fda.gov/drugs/fda-drug-safety-podcasts/fda-identifies-harm-reported-sudden-discontinuation-opioid-pain-medicines-and-requires-label-changes#:~:text=On%20April%209%2C%202019%20FDA,%2C%20psychological%20distress%2C%20and%20suicide.
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45. CDC Media Relations. CDC Advises Against Misapplication of the Guideline for Prescribing Opioids for Chronic Pain. Embargoed Until: Wednesday, April 24, 2019, 5 PM, EDT. See https://www.cdc.gov/media/releases/2019/s0424-advises-misapplication-guideline-prescribing-opioids.html.
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46. Dowell D, Haegerich T, Chou R. No Safecuts to Safer Opioid Prescribing. N Engl J Med 2019; 380:2285-2287. https://www.nejm.org/doi/full/10.1056/NEJMp1904190.
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47. Department of Justice, Office of Public Affairs. Justice Department Obtains $1.4 Billion from Reckitt Benckiser Group in Largest Recovery in a Case Concerning an Opioid Drug in United States History. July 11, 2019. See https://www.justice.gov/opa/pr/justice-department-obtains-14-billion-reckitt-benckiser-group-largest-recovery-case.
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48. McGray D. The Bitter Pill. Wired, April 1, 2005. See https://www.wired.com/2005/04/bupe/.
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49. See https://web.archive.org/web/20150329132943/http://www.rb.com/rb-complete-demerger-of-indivior.
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50. See https://medium.com/@jmkillingworth/grandmas-on-smack-and-other-unsavory-tactics-from-prop-benefactor-reckitt-benckiser-group-fb5ee76a3ed5.
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51. See https://www.govinfo.gov/content/pkg/CHRG-115shrg31264/pdf/CHRG-115shrg31264.pdf.
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52. JAMA. 2019 Sep 4 : e1914523. See https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6727681/?report=printable.
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53. Chou R, et al. Rethinking Opioid Dose Tapering, Prescription Opioid Dependence, and Indications for Buprenorphine. Ann Internal Med, Sept 17, 2019;171(6):427-430. See https://www.acpjournals.org/doi/pdf/10.7326/M19-1488.
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54. Anson P. PROP President Discloses Conflicts of Interest. Pain News Network, November 19, 2019. See https://www.painnewsnetwork.org/stories/2019/11/12/prop-president-discloses-conflicts.
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55 See https://emergency.cdc.gov/coca/transcripts/2016/call-transcript-080316.asp.
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56. Personal communication with Sharon Davies, Letter Editor, British Medical Journal. March 15, 2021, at 2:05 PM ET. (Copy of e-mail available on request from this article’s author).
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57. Agency for Healthcare Research and Quality, US Department of Health and Human Services. Opioid Treatment for Chronic Pain. AHRQ Publication No. 20-EHC011, April 2020. See https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/opioids-chronic-pain.pdf.
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58. Anson P. PROP Linked to New Federal Opioid Study. Pain News Network, April 20, 2020. https://www.painnewsnetwork.org/stories/tag/Roger+Chou
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59. See https://www.regulations.gov/document/CDC-2020-0029-0001.
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60. See https://www.regulations.gov/docket/CDC-2020-0029.
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61. American Academy of Hospice & Palliative Medicine. Letter to Robert R. Redfield, MD, Director, Centers for Disease Control and Prevention. RE: Management of Acute and Chronic Pain: Request for Comment; Docket No. CDC–2020– 0029. June 16, 2020. (PDF copy available on request from this article’s author).
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62. Madara JL. Letter to Deborah Dowell, MD, MPH. Chief Medical Officer, National Center for Injury Prevention and Control, U.S. Centers for Disease Control and Prevention. Re: Docket No. CDC-2020-0029. June 16, 2020. See https://searchlf.ama-assn.org/undefined/documentDownload?uri=%2Funstructured%2Fbinary%2Fletter%2FLETTERS%2F2020-6-16-Letter-to-Dowell-re-Opioid-Rx-Guideline.pdf.
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63. AMA urges CDC to revise opioid prescribing guideline (Press Release). June 18, 2020. See https://www.ama-assn.org/press-center/press-releases/ama-urges-cdc-revise-opioid-prescribing-guideline.
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64. Ballantyne JC et al. Letter to Robert R. Redfield, MD, Director, Centers for Disease Control and Prevention. Re: Docket No. CDC-2020-0029- Management of Acute and Chronic Pain. See http://www.supportprop.org/wp-content/uploads/2020/06/PROP-Comment-CDC-Docket-2020.pdf?fbclid=IwAR2SCNj6MTLhYml9TbthlEm8nfzXQpEQX4tmCGSKFAkptZk42p-OOsKZHZc.
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65. Fudin J. Chronic Opioid Patients Speak Out Against PROP. PainDr, August 12, 2012. See https://paindr.com/chronic-opioid-patients-speak-out-against-prop/ in Comments.
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66. See https://www.cdc.gov/injury/pdfs/bsc/OWG_Terms-of-Ref_FINAL-7-6-2020-r.pdf.
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67. Ross M. Update on the BSC/NCIPC Opioid Workgroup Formation. Board of Scientific Counselors Meeting, July 22, 2020. See https://www.cdc.gov/injury/pdfs/bsc/Ross_OWG-Update-7-7-2020-508.pdf.
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68. See https://www.cdc.gov/injury/pdfs/bsc/OWG-Roster-External-10-13-2020-FINAL-a.pdf.
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69. Ballantyne JC, et al. Letter to Susan R. Bailey, MD, President, American Medical Association. RE: AMA’s Opposition to Dose & Duration Guidance for Opioid Prescribing. February 16, 2021. (PDF copy available on request from this article’s author).
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70. Ballantyne JC, et al. Rapid Response: Letter from Physicians for Responsible Opioid Prescribing (PROP) to the American Medical Association (AMA) -- RE: AMA’s Opposition to Dose & Duration Guidance for Opioid Prescribing. BMJ 2021;372:m4901. See https://www.bmj.com/content/372/bmj.m4901/rr-1.
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71. Levy N, et al. UK recommendations on opioid stewardship. BMJ 2021 Jan 5;372:m4901. See also https://pubmed.ncbi.nlm.nih.gov/33402365/.
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72. Bailey SR. Letter to Physicians for Responsible Opioid Prescribing (PROP). February 19, 2021. https://static1.squarespace.com/static/54d50ceee4b05797b34869cf/t/6036d35738d4d95a0458ab65/1614205783776/AMA+letter+to+PROP.pdf.
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73. Anson P. AMA Scolded for Seeking Changes in CDC Opioid Guideline. Pain Network News, February 17, 2021. See https://www.painnewsnetwork.org/stories/2021/2/17/prop-attacks-ama-for-seeking-changes-in-cdc-opioid-guideline-nbsp.
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74. Pepin JF and Coleman JJ. CDC’s Efforts to Quantify Prescription Opioid Overdose Deaths Fall Short. Pain Ther 2021 Mar 24;1-14. Published online ahead of print on March 24, 2021. See https://pubmed.ncbi.nlm.nih.gov/33761120/ or https://link.springer.com/content/pdf/10.1007/s40122-021-00254-z.pdf.
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75. See screen capture by Carrie Judy at
https://twitter.com/life_is_art___/status/1374453671136616448/photo/1.
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76. Anson P. Kolodny: Critics of CDC Opioid Guideline ‘Twisting the Facts’. Pain News Network, March 24, 2021. See https://www.painnewsnetwork.org/stories/2021/3/24/kolodny-critics-of-cdc-opioid-guideline-twisting-the-facts.
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77. See, for example https://en.wikipedia.org/wiki/Straw_man.
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78. Anson P. PROP Linked to New Federal Opioid Study. Pain News Network, April 20, 2020. See https://www.painnewsnetwork.org/stories/2020/4/20/prop-linked-to-new-federal-opioid-study.
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79. Anson P. CDC Won’t Say Who is Writing Update of Opioid Guideline. Pain News Network, April 5, 2021. See https://www.painnewsnetwork.org/stories/2021/4/4/cdc-wont-say-who-is-writing-update-of-opioid-guideline.
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Pallimed Editorhttp://www.blogger.com/profile/11358791266969988517noreply@blogger.comtag:blogger.com,1999:blog-13495125.post-41498940177532255322021-04-09T08:00:00.035-05:002021-04-10T10:22:52.128-05:00Choosing Palliative Care as a Medical Specialty<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgE9crkBTb-mAMW_HOY7l3eO_ZT8Pt5BH1m8UXMwi405nO6t9y_P4gCJrHzrCh5Ox5nooAUkGpAYWGJvaVnrMKzypE_n3BhnAunYGXG4_dN_py17yZWpwvKLOcGjCPhTQlGGL6lRw/s1080/palliative+care.png" style="display: block; padding: 1em 0; text-align: center; clear: right; float: right;"><img alt="" border="0" width="320" data-original-height="1080" data-original-width="1080" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgE9crkBTb-mAMW_HOY7l3eO_ZT8Pt5BH1m8UXMwi405nO6t9y_P4gCJrHzrCh5Ox5nooAUkGpAYWGJvaVnrMKzypE_n3BhnAunYGXG4_dN_py17yZWpwvKLOcGjCPhTQlGGL6lRw/s320/palliative+care.png"/></a></div>
by Sylvia Lane (<a href="https://twitter.com/sylv_lane" target="_blank">@sylv_lane</a>)
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There are few things more introspective than deciding on a specialty in medicine. The decision forces you to analyze what interests and values you hold but also who you are as a person. How do you solve problems? How do you work with others? What brings you joy? As a third-year medical student, I was able to try on many specialties. Rotating through various fields allowed me to soak up knowledge from almost every type of healthcare professional. But this experience comes with a heavy burden of choosing a future career path.
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From the beginning, I knew that I was not like most of my fellow medical students. Of course, we all share a special bond dealing with the shared stress of progressing through medical education. But I never felt like my perception of medicine was the same as theirs. I always felt sidelined in discussions, scoffed at as the bleeding-heart empath. As I stepped into my third year of medical school, I was filled with enthusiasm to find people who felt like me. People who view medicine in the way that I do. They must exist, right?
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Unfortunately, this was far from my experience. Though each clerkship was a valuable learning opportunity, I continually found something to be missing. Every physician I met was focused on medicine as a cure, while I regularly found myself asking about the impact on the patient’s quality of life and relationships. What will this surgery mean for the patient and their loved ones? How does this treatment impact the patient’s life goals? For me, being a doctor was never about finding a cure. To me, medicine spans not only a patient’s symptoms, diseases, and therapies, but also their family, employment, hobbies, and future. Separating the symptoms from the patient as a human seems impossible to me.
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I came to realize that palliative care was the field I had been looking for. I scoured the internet for all the resources I could find. With bright eyes I started to tell everyone: I found my specialty! However, it was not met with the enthusiasm I was expecting. Every time my friends spoke about their specialty of choice, they were received with positivity, warmth, and excitement. But when I started saying, “I want to do palliative care,” I got a different response. Even through their masked faces, I could see shock and discomfort. Most people responded with one word, “oh,” as they completely changed the subject. I was thrilled to find a specialty that seemed exciting to me, but these encounters made me feel like I was somehow wrong.
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For weeks, I questioned my choice. Was I missing something? Every person I spoke to seemed to be distressed by my decision. Some teachers I respected told me I was wasting my potential or would ultimately change my mind. Discouraged by the sentiments of those around, I turned to Twitter for support from my medical community near and far. The replies I got were nothing like the responses I had received in person. More than 500 people responded with excitement, positivity, and support. Deciding to pursue a career in palliative care had felt good, but in that exact moment I knew it was right. Finding a community of people like me gave me the courage and strength to stay true to myself. And for that, I will be a better physician.
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For more <a href="https://www.pallimed.org/search/label/learners">Pallimed posts about (and/or written by) medical students, residents and other learners, click here</a><br />
For more <a href="https://www.pallimed.org/search/label/lane">Pallimed posts by Sylvia Lane, click here.</a> This is her first post, but someday there may be more!<br>
For some ideas on <a href="https://www.pallimed.org/2021/01/fostering-student-interest-in.html" target="_blank">fostering student interest in palliative care see this Pallimed post.</a>
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<i>Sylvia Lane is a fourth year medical student at the University of Vermont. Between clinical rotations she spends her time perfecting her baking skills, watching new films, and learning how not to kill all her houseplants.</i>
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Pallimed Editorhttp://www.blogger.com/profile/11358791266969988517noreply@blogger.comtag:blogger.com,1999:blog-13495125.post-82800987357614963482021-04-06T19:00:00.006-05:002021-04-07T22:48:33.374-05:00What Is Grief, If Not Love Persevering?: A Palliative Perspective On WandaVision<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhsQNRbGNIscPLqYGkC514v8mMasUYHTsPkcSFrUPwc8YCoWUUCumoH8a95UNNDXNgCDEUJu36ukvFW8bSZ1Tcliy1MDTMN8treV11TXIWbHdtM4GHObI0gdk9D8sI-GjRhiTbA-Q/s1080/pallimed+wandavision.png" style="display: block; padding: 1em 0; text-align: center; clear: right; float: right;"><img alt="" border="0" width="320" data-original-height="1080" data-original-width="1080" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhsQNRbGNIscPLqYGkC514v8mMasUYHTsPkcSFrUPwc8YCoWUUCumoH8a95UNNDXNgCDEUJu36ukvFW8bSZ1Tcliy1MDTMN8treV11TXIWbHdtM4GHObI0gdk9D8sI-GjRhiTbA-Q/s320/pallimed+wandavision.png"/></a></div>
by SarahScott B. Dietz (<a href="https://twitter.com/SDietzMD" target="_blank">@SDietzMD</a>)
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WARNING: THIS POST CONTAINS SIGNIFICANT SPOILERS FOR <i>WANDAVISION</i>.
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In January, <a href="https://www.disneyplus.com/series/wandavision/4SrN28ZjDLwH" target="_blank"><i>WandaVision</i> released on Disney+</a>, promising a weekly serial centered around two romatincally involved and familiar Marvel characters, Wanda Maximoff (aka Scarlet Witch) and Vision. The advertisements showed a black and white, vintage look to the show, and gave few clues as to exactly how it would tie in with the rest of the <a href="https://en.wikipedia.org/wiki/Marvel_Cinematic_Universe" target="_blank">Marvel Cinematic Universe</a>. Fans were intrigued for many reasons, chief among them being that the last time we saw Vision, <a href="https://www.youtube.com/watch?v=5sAF8q0_FqE" target="_blank">he was dead.</a> (CW-Superhero violence/death)
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I dove into <i>WandaVision</i> like many fellow geeks: remote in hand, rewinding to scrutinize frames for clues as to what the "Big Story" was, and trying to solve the mystery before they revealed all. My Nick At Nite viewings of <i>My Three Sons</i> and <i>Patty Duke</i> provided ample cultural references for those first few episodes, and my Marvel lore was at least adequate. But where was it all headed?
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Somewhere around the third or fourth episode, it hit me like a vibranium baseball bat. <i>WandaVision</i> is a study on grief, loss, and mourning, in layers and layers. I took to Twitter, as one does, noting that colleagues in palliative medicine might want to keep an eye on the show. A friend replied, asking why I would think so.
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“It’s Wanda, it’s a giant grief bubble for her. She’s doing this out of grief,” I replied.
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"I see it now,” he said, “It’s like superhero complicated grief.”
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Complicated grief is what happens when the symptoms of loss and mourning do not begin to subside over time, instead worsening and becoming more intense. People struggling with complicated grief become caught up in their emotional turmoil, and the normal healing process is stalled. They dwell in a world colored by their loss, and may seek out items, locations, or sensations that make them feel proximity to the person they have lost.<sup>1</sup>
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Superhero complicated grief is, in other words, a perfect explanation for trapping an entire town of innocent people in order to build a perfect happy sitcom life with your deceased beloved.
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While Wanda is the focus of the story, every character in this series is processing grief stemming from the events in <i><a href="https://marvelcinematicuniverse.fandom.com/wiki/Avengers:_Infinity_War#Plot" target="_blank">Avengers: Infinity War </a></i> and <i><a href="https://marvelcinematicuniverse.fandom.com/wiki/Avengers:_Endgame" target="_blank">Avengers: Endgame</a></i>, most specifically <a href="https://marvelcinematicuniverse.fandom.com/wiki/Snap" target="_blank">the “Snap” in which Thanos exterminated half of all life in the universe</a>. Fifty percent of the population disintegrates in place, in front of their helpless loved ones, only to reappear in exactly the same place five years later. In the hospital in Episode 4, we get a window into the chaos, tension, and anxiety in the moments as people return after five years. Is the man shoving his way through the hallway desperate to call his wife because he is just returning, or is he hoping to hear her voice again for the first time in half a decade? A key character, Monica Rambeau is shown reappearing in the same room where she was with her mother 5 years earlier. Only now her mother is not there in the hosptial bed, and Monica finds out that her mother died in the 5 years she had been 'gone.'
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In Episode 6, Hayward, a main antagonist, growls at Monica that it was so easy for the ones who vanished, they have no idea how hard it was, how much pain those left behind suffered. Even his pain and, yes, grief, is manifest in that short outburst. (The next bit about Monica not having the stomach to sit with her dying mother, though, that’s just an inexcusable snark.)
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Monica’s loss is also heightened by having been disintegrated by the "Snap", and the isolation that she feels as a result. While Monica's mother may have died surrounded by loved ones, Monica was unable to be near her mother, to hold her hand or comfort her in her last moments. Monica has to find her own closure without the benefit of those final good-byes. For too many families, that scenario may hit close to home this year, as COVID-related visitation restrictions have limited our ability to be present with each other, even in times of great need.
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In the midst of all the grief processing and mourning on screen, I appreciated the reference to Vision’s advance directives. I found it satisfying that going against his stated wishes not to be re-animated or used as a weapon was presented as proof of serious transgression. It does make me wonder what the contents of an Avenger’s advance directive would look like. Do they have a standard order form? Does it include circumstances in which resurrection would be acceptable?
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<i>WandaVision</i>’s executive producer and head writer, Jac Shaeffer, <a href="https://deadline.com/2021/03/wandavision-series-finale-interview-jac-schaeffer-dr-strange-2-1234709749/amp/" target="_blank">has shared that they set out to build Wanda’s story arc on the stages of grief</a>: denial, anger, bargaining, depression, and finally acceptance. (2) In retrospect, it’s easy to see that progression. Early in the season, Wanda is perky, the problems are light, and she is cheerfully in denial. We see her sink deep into depression, her kids worried about her. Is there anyone who has gone through the grieving process who did not sympathize on some level with the exploding Wanda, energy radiating out away from her in a messy, undirected eruption of frustration and angry sadness?
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In the midst of a brutal tour of Wanda’s memories and many losses, it is Vision who crystalizes the essence of our journey: “What is grief, if not love persevering?” To lose someone we have lost does not erase the love we have felt for them, it simply moves the object of our love out of reach. Grief is the space left behind, and it is the work of loving someone who is gone.
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<iframe width="560" height="315" src="https://www.youtube-nocookie.com/embed/AKKr1zCSZEQ" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe>
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One of the most moving moments of the show for me was in the very end, when Wanda and Vision were saying goodbye to their boys, and to each other. There was a genuine sweetness to it, tenderness in a scene that could easily be overwrought. It was the superhero version of a farewell I have seen in my practice, occurring in deeply religious families. It is a mix of emotion found in someone with a deeply held belief that they will surely see their beloved again, someday — certain faith that this will happen, blended with uncertainty of what exactly it might look like, and when. Sadness for the parting, even as they trust it will not be forever.
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I am grateful for <i>WandaVision</i> and the conversations it has sparked about grief, loss, and trauma. Marvel being Marvel, we know that even though we have said our farewells this time, we will be able to see these characters again. I can only hope that it will be in a form that is as thought-provoking and enjoyable as <i>WandaVision</i> has been.
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For more <a href="https://www.pallimed.org/search/label/grief">Pallimed posts about grief.</a><br />
For more <a href="https://www.pallimed.org/search/label/media">Pallimed posts about culture and media.</a><br />
For more <a href="https://www.pallimed.org/search/label/dietz">Pallimed posts by Dr. Dietz click here.</a>
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<i>SarahScott B. Dietz, MD practices palliative medicine in western Pennsylvania. She is a life-long geek of many fandoms, and lately has been learning both gardening and how to TikTok. </i>
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<b>Reference</b>
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1 Shear MK. “Grief and mourning gone awry: pathway and course of complicated grief.” Dialogues Clin Neurosci. 2012 Jun;14(2):119-28.
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<meta name="twitter:url" content="https://www.pallimed.org/2021/04/what-is-grief-if-not-love-persevering.html" />Pallimed Editorhttp://www.blogger.com/profile/11358791266969988517noreply@blogger.comtag:blogger.com,1999:blog-13495125.post-310635106633535122021-03-31T08:56:00.000-05:002021-03-31T08:56:36.442-05:00Advance Care Planning? Meh. - Part 2<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj0FBiZ21iWIVBu2sSEQm-RoQWItUYhNeUGPxlg2fgdrizf9tqKQysWlOv7GQV0sYgLIBOoSGkcUX2Zq5rbmdsSNjcrh93mJs3tQZLuEjUq2QpqnOmgoyQOaGGdH2QUAUxRalATtQ/s1080/ADvance+Care+Planning.png" style="clear: right; display: block; float: right; padding: 1em 0px; text-align: center;"><img alt="" border="0" data-original-height="1080" data-original-width="1080" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj0FBiZ21iWIVBu2sSEQm-RoQWItUYhNeUGPxlg2fgdrizf9tqKQysWlOv7GQV0sYgLIBOoSGkcUX2Zq5rbmdsSNjcrh93mJs3tQZLuEjUq2QpqnOmgoyQOaGGdH2QUAUxRalATtQ/s320/ADvance+Care+Planning.png" width="320" /></a></div>
by Drew Rosielle (<a href="https://twitter.com/drosielle" target="_blank">@drosielle</a>)
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This is Part 2/2 of a couple posts about advance care planning (ACP). <a href="https://www.pallimed.org/2021/03/advance-care-planning-meh-part-1.html" target="_blank">The last post outlined</a> why there are really good reasons to believe that ACP (completion of health care directives and the healthcare conversations that occur around healthcare directive (HCD) completion, implemented on a broad scale) does not lead to any better, patient-centered outcomes, particularly when evaluated as a health intervention to be applied across a population (which is how ACP is typically conceptualized and researched).
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<a href="https://www.pallimed.org/2021/03/advance-care-planning-meh-part-1.html" target="_blank">In the prior post</a>, I perhaps obnoxiously promised that I thought one of the most important ACP research studies to occur has just been published, although I think it's important for reasons that weren't necessarily intended by its investigators.
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The <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2775166" target="_blank">study is in JAMA Internal Medicine and was published a couple months ago</a>.
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If you recall from my first post on ACP, one of the challenges with ACP research has been confounding in observational studies. Take an observational study showing that people with HCDs are more likely to have a longer than average hospice length of stay -- that may be true but we don't know why it's true. It could be true because completion of the ACP casually lead to the longer hospice LOS. It could also be true because patients who are inclined towards ACP completion are also inclined towards wanting less 'invasive' EOL care; both of those measurable phenomena stem from underlying personal/social characteristics which presumably emphasize planning, acceptance, surrender, and specific notions of dignity at the EOL which center preferences around being at home (etc) and not being on machines (etc), 'quality over quantity,' what have you.
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One of the tricky things about that is that <i>this sort of confounding may even creep its way into ACP randomized trials</i>, because of the possibility that many patients who are skeptical of ACP or otherwise disinclined to engage in ACP-like activities won't even agree to participate in an ACP trial in the first place. Ie, that the current ACP research is enriched with subjects who are already sort of ACP-accepting, because why else would you put yourself into such a study? This seems like a legit problem and one could even wonder if one of the issues with the prior ACP RCT research showing very little in the way of positive patient-centered outcomes is because such research is only investigating pro-ACP patients anyway who are as a group disinclined towards 'invasive' EOL treatments at baseline so it's tough to show any 'benefit' between the group who got an active ACP intervention vs those who didn't.
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The JAMA IM study utilized a design to try to mitigate that sort of confounding: they prerandomized subjects before obtaining consent, but still compared the 2 groups <u>on the basis of initial randomization</u>, not whether the patients actually consented and received the intervention (this I learned is called a Zelen design). This is tricky so I'll unpack the Zelen design a bit. The idea is you want to study the effects of a real-world ACP intervention, eg what would be the impact of implementing an ACP program aimed at high-risk patients in a healthcare system, say. If you approach patients about the study to get consent, a whole bunch of patients will decline to participate, for all sorts of reasons, including because some are actively disinclined to do ACP. So those folks never enter the study, and you only study 'pro-ACP' people, and you can't really understand how your intervention would actually affect the entire at risk population. With prerandomization you randomize half the at-risk population to the active group initially, <i>then </i>approach the active group subjects for consent. Within the active treatment group, some will consent to receive the ACP intervention, some won't, but when you analyze the data you compare the entire active treatment group (both those who consented to receive intervention + those who declined it) as a whole vs those randomized to routine care because that mimics the actual effects of your intervention in 'real life.' All this is ethical because all the data essentially comes from administrative health care data and everyone just gets 'routine care' unless they actively agree to the ACP intervention.
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The study itself investigated community-dwelling older patients in a 5 county area of North Carolina, and looked at patients only with significant comorbidity/frailty. The ACP intervention was a Respecting Choices ACP program involving a telephone-based nurse-led ACP education visit, followed by the nurse accompanying the patient & a caregiver to a primary care visit where the PCP completed a ACP discussion with prompts to discuss prognosis, disease understanding, unacceptable states at the EOL, and patients' preferred treatment limitations (eg if they wanted a DNR order etc). Providers had an EHR template/platform to document all this. Subjects in the control group received usual care, and their providers had access to the EHR ACP platform but of course no specific actions were taken encouraging/enabling them to use it.
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This is a <i>really, really strong study design</i> compared to some ACP trials. I read the methods section and was like 'Damn, they did this one right.' In particular because it used both a nurse-led education intervention plus staged a prognosis/'goals' discussion with a provider.
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The primary outcome was new documentation of ACP discussions in the EHR after randomization. They measured a variety of secondary outcomes too including healthcare utilization.
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They randomized 765 patients. Of the 379 randomized to the intervention group, about 90 weren't able to be approached for consent to participation (eg they couldn't locate them, etc). Of the 294 approached, 146 consented to the intervention and 139 completed the intervention. Patients had a mean age of 78 years, 60% were women, 17% Black/80% white.
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They crushed their primary outcome: 42% of patients randomized to the intervention group had ACP documentation in the chart vs 4% in the usual care group. They collected some data on patient rating about the quality of ACP communication and patients generally rated it very high.
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Nothing else though seemed to be different between the groups. About 10% of the entire studied population died in the study (median follow up time of 304 days) and there were no differences in the care they received (as measured in the study: ED visits, hospitalizations, etc).
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(In Part 1 post I wondered about studying ACP as a suffering-reducing intervention, and those sorts of outcomes weren't investigated in this study.)
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So, top level summary: this was a really well-designed, well-done, RCT of an ACP intervention which showed it did lead to more completion of ACP but did not impact other measured outcomes about the care patients actually received.
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The question remains for all of us, though: So what? If you think ACP is intrinsically a patient-good then this is a great outcome. But as I discussed before, there is not any sort of clear evidence from the well-done ACP trials that completing ACP changes things that our patients actually care about: reducing suffering, reducing unwanted/burdensome healthcare interventions at the EOL. This current study is another top-notch, well done, study of a comprehensive ACP intervention which could demonstrate no change in these patients' lives apart from having more ACP documented. Yes, they did not measure every patient-centered outcome they could have, but that is not an argument that we should be treating ACP like some standard of care. Instead, best, it should be an investigational intervention, not ready for widespread implementation. If ACP was some sort of drug or medical device and you did a study aimed at getting more people the medical device, and showed in fact that your well-designed intervention successfully lead to more patients getting the medical device, but nothing else measured about the patient's well-being changed, we'd all be like <i>Ok fine study but <i>why should I do this in the absence of patient benefit?</i></i> Same with ACP.
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So why do I think this study was one of the most important ones in recent memory? Fundamentally, I think it's because this study is the best data yet we have that having done ACP is a good proxy for patients wanting 'less invasive' care at the EOL but doesn't in itself change anything.
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This is because of their Zelen design and an incredibly damning (to ACP) exploratory analysis they mention, that compared patients within the randomized-to-being-offered-the-active-intervention group who received the intervention to those who didn't. They found that those patients in the active group who agreed to go through with the ACP interventions had fewer hospitalizations and ED visits than those who declined to. Ie, in the randomized population about half those subjects did not consent to the ACP intervention, and yes those subjects' EOL care looked different from those who consented to receive the ACP intervention. This makes you think maybe the ACP intervention did something. But you need to remember that there was an entire other control group! The people who refused the intervention were not the actual control group! That is, if you compare the entire randomized group to the entire control group (which itself presumably contained an equal measure of ACP-interested and ACP-not interested patients as the randomized group), there were no differences in overall outcomes. Ie, looking at this across the entire population, the ACP intervention made no difference, presumably because <i>the control group itself contained just as many ACP-interested patients as the randomized group.</i> I can't think of any better, available evidence that ACP interventions don't change patient outcomes than this.
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All we're doing is capturing a group of patients who weren't going to allow themselves to die in the hospital regardless.
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No one is saying that ACP activities don't benefit some patients. I've met some patients myself who have benefitted. But millions of dollars are spent each year getting people to fill out these forms. The opportunity cost of that is gigantic. Imagine, if, 25 years ago, when ACP was really kicking off, people did high quality research which came up short, abandoned ACP, and instead all the resources we've spent on it the last generation were spent on investigating other, better ways to mitigate the suffering of our patients with advanced illness, and provide them with the sort of care they actually want. That's what is at stake here.
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For more <a href="https://www.pallimed.org/search/label/advance%20care%20planning">Pallimed posts about advance care planning.</a><br />
For more <a href="https://www.pallimed.org/search/label/rosielle">Pallimed posts by Dr. Rosielle click here.</a>
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<i>Drew Rosielle, MD is a palliative care physician at the University of Minnesota and M Health Fairview in Minneapolis. He founded Pallimed in 2005. You can occasionally find him on <a href="https://twitter.com/drosielle">Twitter at @drosielle</a>. </i>
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<meta content="https://www.pallimed.org/2021/03/advance-care-planning-meh-part-2.html" name="twitter:url"></meta>Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.comtag:blogger.com,1999:blog-13495125.post-32984049421408253172021-03-29T16:42:00.009-05:002021-03-30T10:01:35.613-05:00Advance Care Planning? Meh. - Part 1<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj0FBiZ21iWIVBu2sSEQm-RoQWItUYhNeUGPxlg2fgdrizf9tqKQysWlOv7GQV0sYgLIBOoSGkcUX2Zq5rbmdsSNjcrh93mJs3tQZLuEjUq2QpqnOmgoyQOaGGdH2QUAUxRalATtQ/s1080/ADvance+Care+Planning.png" style="clear: right; display: block; float: right; padding: 1em 0px; text-align: center;"><img alt="" border="0" data-original-height="1080" data-original-width="1080" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj0FBiZ21iWIVBu2sSEQm-RoQWItUYhNeUGPxlg2fgdrizf9tqKQysWlOv7GQV0sYgLIBOoSGkcUX2Zq5rbmdsSNjcrh93mJs3tQZLuEjUq2QpqnOmgoyQOaGGdH2QUAUxRalATtQ/s320/ADvance+Care+Planning.png" width="320" /></a></div>
by Drew Rosielle (<a href="https://twitter.com/drosielle" target="_blank">@drosielle</a>)
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Several years ago I was giving a talk in front of a mostly palliative care audience and asked, "<i>How often do you find yourself, in the care of your patients, saying to yourself something like 'Thank the stars this patient has a healthcare directive (HCD)'?"</i> The overwhelming answer was a bunch of shrugs and people agreeing occasionally (but not routinely) HCDs are helpful.
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For something that seems so central to our work, why is it that so many of my colleagues that day were lukewarm about their utility?
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It's fair to say that the last few months have been a controversial one in the hospice and palliative care communities when it comes to ACP, triggered by Dr Sean Morrison's editorial in <a href="https://www.liebertpub.com/doi/abs/10.1089/jpm.2020.0272?journalCode=jpm" target="_blank"><i>Journal of Palliative Medicine</i>: Advance Directives/Care Planning: Clear, Simple, and Wrong.</a>
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I've been mulling over that editorial for a couple months now and then noticed that, arguably, one of the most important advance care planning (ACP) studies in recent history has just been published, although probably not for the reasons the investigators were hoping for, and I thought I'd write about where we're at a bit for Pallimed.
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This post is going to be about my own thoughts as to why I mostly agree with Dr Morrison's editorial. The next post will be about this tantalizingly important paper that was just published.
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If you haven't read Dr Morrison's editorial, please read it now--it's not that long and it seems to be open access at the moment. Here's his top-level argument:
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<i>As of May 2018, 80 systematic reviews of advance care planning covering >1660 research studies had been published and the National Institutes of Health and the Patient-Centered Outcomes Research Institute had funded >750 research studies at a cost of >$300 million in taxpayer money (an average of $1 million/year). Foundations have spent untold millions. What evidence has all of this research and money wrought? The >1660 studies and 80 systematic reviews on advance directives/care planning have produced only limited and low-quality evidence that advance directives/care planning can actually result in changes in patient, family, clinical, utilization, or financial outcomes. Like the study published in this month's journal, the majority of high-quality research has failed to find a strong link between advance directives/care planning and outcomes of importance. Similarly, despite 30 years of diverse interventions and programs, two-thirds of adults do not have an advance directive (an imperfect yet reasonable surrogate for occurrence of an advance care planning discussion).</i>
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I mostly agree with Dr Morrison about this, and will flesh out my thoughts as to why. I need to note that I didn't run any of this by Dr Morrison so any claims I'm making here about what he thinks are <u>my interpretation of his editorial</u>, sort of my own internal conversation with his editorial, and nothing more; I'm not claiming to speak for him. Also--<a href="https://www.liebertpub.com/toc/jpm/24/1" target="_blank">JPM published many letters in response to his editorial, all of which are worth your time reading.</a>
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I.
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Takes like Dr Morrison's are really controversial (in part) because I think people (clinicians in HAPC), use different definitions of ACP. I sometimes think when people hear stuff like "ACP is not helpful" they think people like Dr Morrison is saying something like "Discussing prognosis and planning for future care with your patients with advanced and serious illnesses is worthless." I.e., this is sort of a 'Big Tent' definition of ACP which includes activities associated with completion of health care directives + really any clinical activity that's in the realm of discussing the future (eg discussions of prognosis, preparing patients for future decisions/what is likely to happen to them in the future, even goals of care discussions). I'm pretty sure though that Dr Morrison and the other detractors of ACP, when they say there's no evidence it actually helps patients, are really talking about the <u>narrow definition of ACP</u> (completion of HCDs and the clinical/healthcare discussions that occur adjacent to HCD patient education and completion), and are not criticizing the idea we should be discussing prognosis / the future with our seriously ill patients.
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Also, because I know some of you will be reading this and asking, "<i>But what about Physician Prders for Life-Sustaining Treatments (POLSTs)</i>?"-- for all intents and purposes the following discussion is not really about the <a href="https://polst.org/" target="_blank">POLST movement</a> (which is not to say POLSTs have the sort of evidence behind them we'd like either, but that's another story). All this isn't really about <a href="https://www.ariadnelabs.org/areas-of-work/serious-illness-care/" target="_blank">Ariadne's Serious Illness Care project</a> either, and importantly I'll note the Ariadne investigators are doing their best to study their intervention in multiple settings and are not advocating wholesale population wide implementation of their program in the absence of evidence (which is what was done with ACP the last decades).
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II.
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One could note that there really isn't great evidence for talking with seriously ill patients about prognosis/planning for future care either. That is sort of true, there is some research but not enough and not overwhelmingly convincing (one could look at the <a href="https://www.ariadnelabs.org/areas-of-work/serious-illness-care/research/" target="_blank">recent Ariadne Serious Illness work for some examples</a> of what I mean by sort of true) but honestly I'm less 'worried' about that because as a physician I have a professional obligation to discuss prognosis with my patients. I can't help them make informed care decisions otherwise, and honestly I'm less interested in outcomes research focused on <i><b>if</b> I should be talking with my patients about the future</i> than <i><b>how</b> I should be talking with them about the future.</i> I want to learn better/more effective/more compassionate/more accessible/more timely/more culturally- and patient-centered ways of having those conversations, not whether or not I should be having them.
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At the same talk I mentioned above, for instance, when people admitted they rarely have found ACPs to be helpful in real clinical practice, I asked people how often are they glad that someone before them had had a realistic discussion with a patient about the future, and everyone indicated that they found this routinely helpful of course.
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III.
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The same is not true with narrow definition ACP (and from here on out when I say ACP I am only talking about the narrow definition). ACP was adopted as a healthcare innovation really without the sort of scrutiny and demand for proof that it actually helped patients that we'd demand for other innovations like, say, LVADs. The acceptance of ACP as unimpeachably a good, obvious, thing for our patients is so entrenched that people have funded entire careers off of studying how to get people to do ACP, without there being reasonably clear evidence it actually improves patient-centered outcomes.
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Much of the ACP research out there is focused on projects/methods to get patients/clinicians to do ACP. I'm not claiming this is bunk research, some of it is really high quality work, however I am claiming that it's high quality work which seems to assume we are benefitting patients by helping them do ACP yet we don't actually yet know that. Importantly here, if you are reading this and thinking to yourself something like <i>I just saw a patient the other day who seemed to benefit in some way from ACP</i> I am not saying you're wrong. I've met that patient too. But, like with anything, acknowledging there are a few patients which benefit from something is very different than concluding something should be a routine, integral part of medicine, implemented widely as a public health intervention, and worth the immense amount of healthcare and research investment of time and dollars spent on it.
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I think Dr Morrison's thesis is "<u>ACP is not worth the time/money/effort that has been spent on it as a public health intervention</u>," not "ACP has never helped anyone."
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IV.
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Some ACP research has been about 'congruence,' whether doing ACP activities predicts whether you will later on get the care/treatments you at a prior date said you would want. Especially in the early days of ACP most of the talk was about 'autonomy' and making sure people get what they want, etc. (Indeed, much of the early talk about ACPs was really centered on things like patient rights and autonomy.) There is a moral and philosophical discussion to be had about that topic and whether this is something we should actually be trying to achieve (because patients wishes change over time, and how can patients really make informed decisions about future health states without actually being in such a state, and does it even make sense to ask patients to sort of 'pre-decide' healthcare decisions which on a good day are bleedingly complicated even for cognitively intact and emotionally stable patients). It's an interesting topic, but it doesn't really matter anyway, because there's no high quality research into congruence showing ACP does anything anyway.
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To take a couple examples, there is this very well done <a href="https://www.bmj.com/content/340/bmj.c1345" target="_blank">Australian study from 2010 in the BMJ</a> (the "Melbourne Study") which did a comprehensive ACP intervention in high risk hospitalized older patients. If you read the abstract you'll think that the intervention improved 'congruence' (meaning patients who did the ACP intervention were more likely to get congruent care than those who didn't). If you actually read the study you'll realize that what the intervention group had was better documentation of their wishes so it was easier to 'prove congruence for them (we don't know if the control group had 'congruent' care because their wishes weren't documented) and we don't actually know if the ACP intervention changed any patient care. The 2nd example is the only RCT that I'm aware of the highly revered Respecting Choices ACP model which looks at congruence. This was a RCT of 300 high risk patients (severe heart failure or were on dialysis) who received usual care or the Respecting Choices intervention. This carefully done prospective trial which followed patients long term showed absolutely no improvement in congruence. Think about this one--this wasn't a study of healthy elders, this was a study of people at really high risk of dying (ie the people most likely to benefit from ACP), 300 of them, and <u>yet they couldn't show any difference</u>. It's research like this that Dr Morrison is pointing to I believe when he says ACP has not been shown to benefit patients.
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V.
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Many of you are probably aware though of all sorts of positive ACP research. People who have HCDs are, compared with those patients who don't have them: more likely to have DNR orders at the end of life, more likely to spend more time enrolled in hospice, less time in ICUs at the end of life, etc. <i>We have a couple decades of research showing this in multiple settings.</i> The problem with this is that nearly all this research which has shown these lovely associations is observational, subject to major confounding. And there is every reason to believe there is huge confounding at play in this sort of research. That is, patients who are open/inclined towards participation in ACP activities are probably more inclined to want 'less intensive' EOL treatments. Think about your own patients, there is a group of them for whom participating in ACP is pretty easy, they want to do it, it's emotional for them but they are committed to it without much encouragement from us, etc. I think there's every reason to believe that the average patient like that is also far more disinclined to want 'invasive' EOL treatments than patients who will not participate in ACP. What this ends up meaning is that <i>having a HCD may just be a proxy for also being disinclined to want 'invasive' EOL treatments</i>, and the <i>actual process of completion of the HCD doesn't impact care one way or the other</i> because these patients already are the folks who are inclined to enroll in hospice earlier, etc. Again, when you do prospective, controlled research, it's much more difficult to show any patient-centered 'benefit' or change in outcomes, apart from the fact that more ACP is documented, even when you are using one of the most highly investigated and validated ACP tools out there, <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2767898">such as in this trial</a>.
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VI.
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I disagree with Dr Morrison on one major point--he seems to be advocating that we wholesale abandon ACP as a clinical and research endeavor. I think there is one domain of patient outcomes which is really under researched, and ACP may really help. This is the possibility that ACP's main benefit to patients/families is essentially a palliative benefit to reduce iatrogenic emotional suffering we in healthcare cause our patients/families due to our decades' long abandonment of our dying patients by forcing them to make decisions they don't want to make. Because we have moved in the last few decades to a situation in which we have decided that desperate, grieving family members are the defacto best people to decide, for instance, if and where tubes should be inserted into their dying family members' bodies, we have caused tremendous suffering, and ACP may be a way of mitigating that suffering. I think this idea has potential and it has increasingly been a subject of investigation in the last decade, which I'm glad to see, although it's still not being investigated routinely. For example the Melbourne Study, while it didn't clearly show any other benefit, <i>did show decreased stress and anxiety symptoms in family members</i> who participated in the ACP process.
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This is presumably what Ira Byock meant when he said "I have an advance care directive not because I have a serious illness but because I have a family.” Ira, of course, might be on to something there, and it's been frustrating to me that so few investigators have taken up that outcome as a primary focus of ACP. Admittedly, it's a bit obscene to say it's just iatrogenic suffering here which ACP might mitigate, of course it isn't, and there may be emotional and social benefits outside that--families talking about what's important together, memory and legacy making that can occur adjacent to ACP completion, etc. What I am essentially proposing is that ACP could be studied in a way that's sort of similar to how the <a href="https://dignityincare.ca/en/" target="_blank">Dignity Therapy</a> investigators approach their intervention. ACP is <u>not</u> Dignity Therapy, however I'm arguing it could be investigated as a sort of analogous <u>suffering-reducing, meaning-making intervention.</u>
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Importantly, I am not proposing here that we just shift uncritically from saying ACP is good not because it's all about 'honoring'/'respecting' choices (the pre-decisions, autonomy model), or because it reduces unnecessary healthcare costs / keeps people out of ICUs when they are dying, but because it reduces suffering. <i>It's premature to say that</i>. We can't put the cart before the horse. ACP may yet be worthless as a broadly enacted healthcare intervention, and we should continue to consider any benefits hypothetical until proven otherwise
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For more <a href="https://www.pallimed.org/search/label/advance%20care%20planning">Pallimed posts about advance care planning.</a><br />
For more <a href="https://www.pallimed.org/search/label/rosielle">Pallimed posts by Dr. Rosielle click here.</a>
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<i>Drew Rosielle, MD is a palliative care physician at the University of Minnesota & M Health Fairview in Minneapolis. He founded Pallimed in 2005. You can occasionally find him on <a href="https://twitter.com/drosielle">Twitter at @drosielle</a>. </i>
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<meta content="https://www.pallimed.org/2021/03/advance-care-planning-meh-part-1.html" name="twitter:url"></meta>Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.comtag:blogger.com,1999:blog-13495125.post-80110677243400487922021-03-22T14:18:00.002-05:002021-03-22T14:18:39.256-05:00On the Value of Social Work in Palliative Care<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgL-XC_H2a7ZDY1NcwJnDWSbnJ2KUld5Y5_gIpCTrXBd93Zwljfub7cHnqU_Xh3n1YSyz0wS6CV2QgLBQBAiP_HD-SwOHf_imlwmZwVmQui2m0Ct6sz5g32Hx075ZNKzT4rAT2iYQ/s1080/transdermal+fent+to+methadone+%25283%2529.png" style="display: block; padding: 1em 0; text-align: center; clear: right; float: right;"><img alt="" border="0" width="320" data-original-height="1080" data-original-width="1080" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgL-XC_H2a7ZDY1NcwJnDWSbnJ2KUld5Y5_gIpCTrXBd93Zwljfub7cHnqU_Xh3n1YSyz0wS6CV2QgLBQBAiP_HD-SwOHf_imlwmZwVmQui2m0Ct6sz5g32Hx075ZNKzT4rAT2iYQ/s320/transdermal+fent+to+methadone+%25283%2529.png"/></a></div>
by Vickie Leff (<a href="https://twitter.com/vickieleff" target="_blank">@VickieLeff</a>)
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Another year, another study proving the value of the palliative care social worker. Edmonds et al (2021) found that when a social worker was involved in a palliative care consultation, whole-person care components were more likely to be addressed, including addressing psychological (82% vs 18%) and spiritual needs (92% vs 8%) and documenting advance directives (90% vs 10%). This adds to what we already knew: involvement of social work impacts quality of care and patient satisfaction (Auerbach, 2007; O’Donnell et al., 2018).
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It surprises me that despite much research and team role development, palliative care team members may not be aware of the importance of the palliative care social worker. And yet, as a Hospice Social Worker, in the year of the pandemic, I was considered non-essential. I was not the only one. Around the country, I heard stories of many palliative care and hospice social workers being sent home. Unfortunately, many articles had to be written this year arguing that the social worker is essential (Guerrero 2020; Lipe 2020; Abrams 2020; Gewirtz 2020). Still, so many of us continue to be asked: What does a palliative care social worker do?
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If what you know about social workers comes from TV you would think we primarily work for child protective services. If all you know of us is what you see in your ambulatory clinic you might think a social worker is only helpful for ordering a patient oxygen or a rolling walker. These misconceptions are common. After all, the profession of Social Work is represented in many different fields of practice. Our educational training varies and there are many levels and degrees one can have to be called a social worker.
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There is a wide range of variation for social work practice in the healthcare setting. Hospitals have social workers as case managers doing discharge planning; some are employed as behavioral health specialists, substance use experts and counselors, and population health managers; some clinical social workers are on Palliative Care teams providing extensive psychosocial care; and some are cognitive behavioral therapy experts in the outpatient setting. Quite a wide gamut. This broad range of practice is both a strength and a challenge for the social work profession because it can make it difficult for others to understand our value.
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As March is social work month, let’s spend some time reflecting on the value of social work within the palliative care team. So here is what we do…. (this is not all inclusive!)
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Broadly, we provide psychosocial care to patients and families. We are mental health providers who are trained to facilitate family meetings, manage family dynamics, and assess and treat anxiety and depression. We provide counseling to patients, children, and families. We assess for pain, spiritual needs, and advocate for a clear plan of care. We have advance care planning conversations and help to locate resources for patients and families.
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We have an expert understanding of the social determinates of health and engage in cultural curiosity, often helping reframe concerns for our team members. For instance, we interpret medical information for the patient and family (think of your patients asking, “What did they just say?”). We coach surgeons prior to a “difficult” conversation, sharing our insight about family dynamics, use of language, and culture to guide them. We listen to the moral distress from bedside nurses in ICU units, offering strategies for well-being. We are often the team member who takes responsibility for team wellness and reflection, helping our colleagues identify their own reactions to difficult cases.
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Palliative care social work has come a long way. Like our physician and nursing colleagues, we now have our own evidence-based certification: <a href="http://www.aphsw-c.org/" target="_blank">the APHSW-C</a>. We have a national organization of 1,000 members – the Social Work Hospice and Palliative Network (SWHPN) and over 10 social work fellowships across the country, to train post-masters social workers in specialty level palliative care.
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All palliative care team members listen with their own attention, intention, and biases. That is surely the beauty of working as a team, learning and depending on each other to provide the best care. As Rosa, et.al. suggests, we have an opportunity, right now, to become transdisciplinary teams “co-creating a unified framework for delivering palliative care that transcends disciplinary perspectives.” (Rosa et.al., 2020) This transcendent palliative care team requires that we all commit to having a shared understanding of each other’s value. While social work may be a large umbrella, our role in serious illness care is clear and rooted in data. Please stand with us and use your voice to tell others about our value: We are crucial members of the palliative care team and we are essential.
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For more Pallimed posts by <a href="https://www.pallimed.org/search/label/leff" target="_blank">Vickie Leff, click here.</a>
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For more Pallimed posts about <a href="https://www.pallimed.org/search/label/social%20workers" target="_blank">social workers, click here.</a>
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<i>Vickie Leff, LCSW, APHSW-C is the Executive Director of the Advanced Palliative & Hospice Social Work Certification Program; she is also an Adjunct Instructor at the UNC School of Social Work, Chapel Hill. She still thinks that running a 6 hour marathon is actually a really good finish time.</i>
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<b>References</b>
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Abrams, L. S., & Dettlaff, A. J. (2020). Voices from the Frontlines: Social Workers Confront the COVID-19 Pandemic. Social work, 65(3), 302–305. <a href="https://doi.org/10.1093/sw/swaa030" target="_blank">https://doi.org/10.1093/sw/swaa030</a>
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Auerbach, C. (2007). Evidence that Supports the Value of Social Work in Hospitals. Social Work in Health Care, 44(4), 17–32. <a href="https://doi.org/https://doi.org/10.1300/J010v44n04_02">https://doi.org/https://doi.org/10.1300/J010v44n04_02</a>
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Edmonds, K. et al (2021). <a href="https://www.jpsmjournal.com/article/S0885-3924%2821%2900211-6/fulltext" target="_blank">An Exploratory Study of Demographics and outcomes for Patients Seen by Specialist Palliative Care Social Work in the Inpatient Setting at an Academic Center</a>. Journal of Pain and Symptom Management.
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Gewirtz, R. (2020) As I See It: Social Workers are Essential personnel; So, why aren’t we talking about them? Retrieved from: <a href="https://www.telegram.com/news/20200330/as-i-see-it-social-workers-essential-personnel-so-why-arent-we-talking-about-them" target="_blank">https://www.telegram.com/news/20200330/as-i-see-it-social-workers-essential-personnel-so-why-arent-we-talking-about-them</a>
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Guerrero, L., Avgar, A., Phillips, E., Sterling, M. (2020). They are Essential Workers now, and should continue to be: Social Workers and Home Health Care workers during COVID-19 and Beyond. Journal of Gerontological Social Work.<a href="about:invalid#zSoyz" target="_blank"> http://doi.org/10/1080/01634372.2020.1779162</a>
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Lipe, L. (2020) Social Workers are Essential Workers. Retrieved from: <a href="https://www.socialworker.com/feature-articles/practice/social-workers-essential-workers/" target="_blank">https://www.socialworker.com/feature-articles/practice/social-workers-essential-workers/</a>
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O’Donnell, A. E., Schaefer, K. G., Stevenson, L. W., DeVoe, K., Walsh, K., Mehra, M. R., & Desai, A. S. (2018). Social Worker-Aided Palliative Care Intervention in High-risk Patients With Heart Failure (SWAP-HF): A Pilot Randomized Clinical Trial. JAMA Cardiology, 3(6), 516–519. <a href="https://doi.org/10.1001/jamacardio.2018.0589" target="_blank">https://doi.org/10.1001/jamacardio.2018.0589</a>
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Rosa, W. et al (2020) Coronavirus Disease 2019 as an Opportunity to Move toward Transdisciplinary Palliative Care. Journal of Palliative Medicine, 23(10), pp. 1290–1291.<a href="http://doi.org/10.1089/jpm.2020.0306" target="_blank">http://doi.org/10.1089/jpm.2020.0306</a>
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<meta name="twitter:url" content="https://www.pallimed.org/2021/03/on-value-of-social-work-in-palliative.html" />Pallimed Editorhttp://www.blogger.com/profile/11358791266969988517noreply@blogger.comtag:blogger.com,1999:blog-13495125.post-69246723565670266122021-03-22T14:16:00.004-05:002021-03-22T14:16:53.362-05:00Palliative Care Social Worker Infographic<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhsNPpxizyoZ4JrFup3NIKXDWxGDPcPMkYS2PEi22h5gRiQsqCrZ-a9M4bWE3jQI1yevV74YatbbWEe_aGBC4J7NFJy1nifMCChfziwiCIJuGeKEfvw6yO9dWtkEB3_c41l4Xtafg/s2804/PCSW+Infographic-1.png" style="display: block; padding: 1em 0; text-align: center; "><img alt="" border="0" height="600" data-original-height="2804" data-original-width="1122" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhsNPpxizyoZ4JrFup3NIKXDWxGDPcPMkYS2PEi22h5gRiQsqCrZ-a9M4bWE3jQI1yevV74YatbbWEe_aGBC4J7NFJy1nifMCChfziwiCIJuGeKEfvw6yO9dWtkEB3_c41l4Xtafg/s600/PCSW+Infographic-1.png"/></a></div>Pallimed Editorhttp://www.blogger.com/profile/11358791266969988517noreply@blogger.comtag:blogger.com,1999:blog-13495125.post-35196791162524701202021-03-15T16:31:00.008-05:002022-05-13T10:56:42.597-05:00What Remains of Edith Finch? - A Video Game Review<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgwTsn5qBccqlsPb_x4fuNzjkIrNiTaycuGlCy2i7Qs2gR0Gh9Tm1c0pRryNRlU7RMNQostE3Msbkcsm6pN6oNZd_un5yhj-AhydHF1eFleVoF0neVEPr2jrOMv7v3NBK0nFSFK9w/s1080/What+Remains+of+Edith+Finch_.png" style="display: block; padding: 1em 0; text-align: center; clear: right; float: right;"><img alt="" border="0" width="320" data-original-height="1080" data-original-width="1080" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgwTsn5qBccqlsPb_x4fuNzjkIrNiTaycuGlCy2i7Qs2gR0Gh9Tm1c0pRryNRlU7RMNQostE3Msbkcsm6pN6oNZd_un5yhj-AhydHF1eFleVoF0neVEPr2jrOMv7v3NBK0nFSFK9w/s320/What+Remains+of+Edith+Finch_.png"/></a></div>
by Matthew Tyler (<a href="https://twitter.com/PalliDad" target="_blank">@PalliDad</a>)
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Fortunately for me, the pandemic has not interfered with my life-long hobby: video games. I finally got around to playing <i>What Remains of Edith Finch</i>, a game that received high praise for its short but engrossing Lovecraftian-esque narrative. What I experienced was a surprisingly insightful exploration of humanity’s relationship with death.
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Coincidentally, I had just read <a href="https://www.nytimes.com/2020/12/18/opinion/sunday/coronavirus-death.html" target="_blank">BJ Miller’s opinion piece “What is Death?” in The New York Times</a> and was struck by the parallels between it and What Remains. This game illustrates how one may “fold death into our lives,” and what can happen when we refuse to do so. As Dr. Miller says, “We really have only two choices: to share life with death or to be robbed by death.”
<i>What Remains</i> doubles down on this sentiment by turning tragedy on its head and daring us to find beauty in every story (or video game), no matter how short.
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<i>What Remains</i> centers on a young woman named Edith Finch who returns to her childhood home following the death of her mother. Now the last member of her family, Edith is searching for an explanation for the infamous Finch Family Curse. For reasons unknown, the tragedy of untimely death has stalked the Finch family for countless generations.
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Over the course of the game, you explore the rooms of her deceased relatives in order to make sense of her family’s misfortune. Browsing journals and photographs of Edith’s deceased relatives momentarily transports you to the moment before each person’s death, allowing you to temporarily see the world through their eyes. A warning: these scenes are brief but intense and include death by suicide. While you do gain information about the circumstances of each family member’s death, many questions are left unanswered.
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What I found more captivating than the mystery of the curse was the variety of ways the family copes with terrible loss. The game places particular focus on the narratives of Edith’s mother, Dawn, and Edith’s great-grandmother, Edie. Edie, now in her 90s, has lived in the family home since she and her late husband built it 80 years prior. Over the years she has lost her husband, five children, two grandchildren, and two great-grandchildren within the home. Instead of turning away from this massive heartache, Edie preserves each room as a memorial to celebrate the person that lived inside it. She refuses to repurpose these rooms for new family members, and instead tacks on new rooms to the house whenever needed. As a result, the house takes on a haphazard, other-worldly appearance as if it were a living organism.
<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi1djk-J-aEsamBwvZsBwm7k5hwXOpyOv38TPasz6hG3Ok3MSINPGqKnm6Kt8kKVjcrhUqOQMst3CCsbxnB85Obi5kmzWwCsl8uwPdfybJVjVGpPr62Tt_Sc6OXnlAVQVux5N3jww/s1280/image1.jpeg" style="display: block; padding: 1em 0; text-align: center; "><img alt="" border="0" width="320" data-original-height="720" data-original-width="1280" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi1djk-J-aEsamBwvZsBwm7k5hwXOpyOv38TPasz6hG3Ok3MSINPGqKnm6Kt8kKVjcrhUqOQMst3CCsbxnB85Obi5kmzWwCsl8uwPdfybJVjVGpPr62Tt_Sc6OXnlAVQVux5N3jww/s320/image1.jpeg"/></a></div><br><br>
Dawn, on the other hand, is terrified of her family’s past and eager to conceal it from her children. Rather than discuss death with her children, she seals off the memorialized rooms and refuses to talk about their relatives. However, as Dawn finds out and as we in palliative care know, it is impossible to insulate loved ones from loss forever. When Dawn dies, Edith is left to uncover her family’s history – and navigate the pain associated with what she finds – entirely on her own.
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So often in palliative and hospice care we bemoan our culture’s aversion to the topic of death and dying. Experiencing <i>What Remains</i> and reading its overwhelmingly positive reviews gives me hope that the aversion may not be as strong as we think. On the contrary, it would seem there is a hunger to explore the existential in more ways than we realized -- even if some are slightly unconventional.<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEijlN67trp3ZdJkmzGIkh-WRgW3of0Izb4vzdTzts6e-KQoeifnqeRB0RaPi2coBZ0aI48z0xPhVdi8Yfxfw6ICHAIOjJE4ezwtUwz8rOFFmoySZBspp_oanQH0kctcDOSd9mFB0A/s512/wroef.jpg" style="display: block; padding: 1em 0; text-align: center; clear: right; float: right;"><img alt="" border="0" width="320" data-original-height="269" data-original-width="512" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEijlN67trp3ZdJkmzGIkh-WRgW3of0Izb4vzdTzts6e-KQoeifnqeRB0RaPi2coBZ0aI48z0xPhVdi8Yfxfw6ICHAIOjJE4ezwtUwz8rOFFmoySZBspp_oanQH0kctcDOSd9mFB0A/s320/wroef.jpg"/></a></div>
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<i>“If we lived forever, maybe we'd have time to understand things. But as it is, I think the best we can do is try to open our eyes. And appreciate how strange and brief all of this is.”</i> --Edith Finch
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<i><a href="http://www.giantsparrow.com/games/finch/" target="_blank">What Remains of Edith Finch?</a></i> is available to play on PlayStation, Xbox, and Windows (via Steam).
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<iframe width="560" height="315" src="https://www.youtube-nocookie.com/embed/4mrx1G26GTQ" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe>
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For more Pallimed posts on <a href="https://www.pallimed.org/search/label/video%20games" target="_blank">video games, click here.</a>
For more <a href="https://www.pallimed.org/search/label/tyler">Pallimed posts by Dr. Tyler click here.</a><br>
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<i>Matt Tyler is a palliative care doctor in Chicago. If he's not watching Cocomelon with his daughters, he is probably playing video games or making <a href="https://www.tiktok.com/@pallidad?_d=secCgYIASAHKAESMgowgwzhy7W1EsPN1Nh2pUMIddn1wvREg0j6yyBBJ76O8ZsGO7d80%2BzKIOda93yPpfIhGgA%3D&language=en&preview_pb=0&sec_user_id=MS4wLjABAAAA7-9ruKPrYrM3-EozY28i1X0XH8vFJVD5b15Cn1EapcyLD33SqG4qSHj2ttXXxqrW&share_item_id=6933597602348797189&share_link_id=BADC1D5C-E16A-43EF-BD9D-CD97D21F4C44&timestamp=1614356071&tt_from=twitter&u_code=dh23cf6kk0g28i&user_id=6927074031583200262&utm_campaign=client_share&utm_medium=ios&utm_source=twitter&source=h5_m" target="_blank">palliative care skits on TikTok.</a></i>
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<meta name="twitter:url" content="https://www.pallimed.org/2021/03/what-remains-of-edith-finch-video-game.html" />Pallimed Editorhttp://www.blogger.com/profile/11358791266969988517noreply@blogger.comtag:blogger.com,1999:blog-13495125.post-54467575884430578412021-02-16T18:00:00.003-06:002021-02-17T17:27:43.111-06:00Pallimed GeriPal Virtual Gathering 2021<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4y3CLlCPqaRLeUf1bfyChGehrrglOu3sJVpR6LP65MypeEe6Rgjg4kY1mJjSC_XqdP1RT61ITDFLol5wV_fTG4TGP_ljLBnd2j41Dvq_G4h6gUNbm5_h6M2uXT80xnej67NjHDQ/s1080/Pallimed+GERIPAL+PARTY+%25281%2529.png" style="display: block; padding: 1em 0; text-align: center; clear: right; float: right;"><img alt="" border="0" width="320" data-original-height="1080" data-original-width="1080" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4y3CLlCPqaRLeUf1bfyChGehrrglOu3sJVpR6LP65MypeEe6Rgjg4kY1mJjSC_XqdP1RT61ITDFLol5wV_fTG4TGP_ljLBnd2j41Dvq_G4h6gUNbm5_h6M2uXT80xnej67NjHDQ/s320/Pallimed+GERIPAL+PARTY+%25281%2529.png"/></a></div>
by Christian Sinclair (<a href="https://twitter.com/ctsinclair" target="_blank">@ctsinclair</a>)
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Short notice, but yes, there will be a Pallimed/GeriPal virtual party this year. <a href="https://www.pallimed.org/2020/03/14th-annual-pallimed-party-aka-un.html" target="_blank">Never missed a year!</a> Have we planned a lot around this? No. Do we want to see friends and colleagues and meet new people? Yes. Can we do it with minimal expectations? We hope so!
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We are not sure what to expect, but when we did this in person there was never that much of a plan anyway, except where to go next, and even that was up for improvisation.
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So what might we do. Probably hang out in different Zoom rooms talking about different subjects, playing games, talking about palliative care things, or maybe not palliative care things.
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When: Wednesday, Feb 17, 2012<br>
Where: Zoom invite via email sent by email at 5p CT
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UPDATE: Invites have been sent. Ping @ctsinclair or @pallimed on Twitter and we will try to add you before 9p ET.
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Reserve time on your calendar now! Share this with your friends. Get them registered too.
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Keep an eye out on the Twitter accounts of <a href="https://twitter.com/pallimed" target="_blank">Pallimed</a> and <a href="https://twitter.com/geripalblog" target="_blank">GeriPal</a> just in case this thing goes big and we need to make alternative plans.
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<meta name="twitter:url" content="https://www.pallimed.org/2021/02/pallimed-geripal-virtual-gathering-2021.html" />Christian Sinclairhttp://www.blogger.com/profile/14685043408496367587noreply@blogger.comtag:blogger.com,1999:blog-13495125.post-33010454804278621372021-01-30T09:46:00.004-06:002021-01-30T14:57:57.165-06:00Confronting Stigma From Opioid Use Disorder in Cancer Care<div><insert here="" picture=""><p dir="ltr" style="background-color: white; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;"></p><div class="separator" style="clear: both; text-align: left;"><span style="font-size: 16px; white-space: pre-wrap;">by Fitzgerald Jones, Ho, Sager, Rosielle and Merlin</span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-size: 16px; white-space: pre-wrap;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-size: 12pt; white-space: pre-wrap;">Have you ever been so distressed by a perspective piece that it kept you up at night? The type of rumination that fills you with so much angst that you have no choice but to act. </span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-size: 12pt; white-space: pre-wrap;"><br /></span></div><p dir="ltr" style="background-color: white; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">This is exactly how we felt when we read the <a href="https://aahpm.org/quarterly/winter-20-lets-think-about-it-again" target="_blank">AAHPM Quarterly Winter 2020 Let’s Think About It Again</a>.</span><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-size: 0.6em; vertical-align: super;">1</span></span> <i>(member paywall)</i></p><p dir="ltr" style="background-color: white; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;"></p><div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg0-sEty5b6qZdJx-ldZj9FIQ_PFOGAzSizpQJTEY_p4ypmYTSsV7ZJcJYk0AJTw8kEdk729i0T85uzNhMnm5vvIQ5rTUvRRhw-_lGz3Y8t95ZRrl6nLeVotSPMa2ZgHVza2kL_RA/s1080/OUD+Post+%25285%2529.png" style="clear: right; display: block; float: right; padding: 1em 0px; text-align: center;"><img alt="" border="0" data-original-height="1080" data-original-width="1080" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg0-sEty5b6qZdJx-ldZj9FIQ_PFOGAzSizpQJTEY_p4ypmYTSsV7ZJcJYk0AJTw8kEdk729i0T85uzNhMnm5vvIQ5rTUvRRhw-_lGz3Y8t95ZRrl6nLeVotSPMa2ZgHVza2kL_RA/s320/OUD+Post+%25285%2529.png" width="320" /></a></div><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">The column, which is structured as a sort of written debate in which two authors argue a clinical question, describes a case of a 45-year-old man with severe substance use disorder (SUD) recently diagnosed with extensive-stage small-cell lung cancer. He was offered aggressive chemotherapy and a referral to a clinic to address his opioid use disorder but did not follow up in the SUD clinic and later presented to an emergency department after a heroin overdose that reversed with naloxone. At his oncology follow-up, he expresses a desire to proceed with chemotherapy but a reluctance to take medication for addiction, stating he can manage his heroin use on his own. The case notes a history of long standing depression and recent homelessness. The column then poses the question: </span><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; font-weight: 700; vertical-align: baseline; white-space: pre-wrap;">Should a patient be offered chemotherapy if he does not receive appropriate care for his ongoing SUD? </span><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Two authors then wrote their different responses to that question (yes give him chemo, or no). </span><p></p><p dir="ltr" style="background-color: white; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-size: 12pt; font-style: italic; font-variant-east-asian: normal; font-variant-numeric: normal; font-weight: 700; vertical-align: baseline; white-space: pre-wrap;">Should a patient be offered chemotherapy if he does not receive appropriate care for his ongoing SUD? </span></p><p dir="ltr" style="background-color: white; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">If this question does not immediately cause you to feel intense discomfort, we suggest you pause and consider why this might be. We think even asking the question this way is harmful, as it presents as a reasonable option denying a middle aged patient with a highly treatable cancer standard medical care, due to having opioid use disorder (OUD) as a comorbidity. </span></p><p dir="ltr" style="background-color: white; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Fundamentally, the question is about who we think is deserving and able to receive cancer treatment. </span></p><p dir="ltr" style="background-color: white; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Keep in mind here - this is a discussion about untreated small cell lung cancer, one of the most highly aggressive yet chemotherapy-responsive solid tumors we encounter. Without chemotherapy, this patient will almost certainly die in 1-2 months. While extensive stage small cell lung cancer is not curable, with treatment, there is a reasonable chance he could live a year, and with newer therapies some patients are now living substantially longer. His ongoing heroin use is undoubtedly a source of significant suffering for the patient, and is a comorbidity which will complicate his care, require intense help, and may possibly shorten his life, but asking if we should even bother to treat this patient’s cancer is asking whether we think his life has value.</span></p><p dir="ltr" style="background-color: white; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-size: 12pt; white-space: pre-wrap;">Ie, is dying in 2 months from untreated cancer alongside suboptimally treated OUD an acceptable alternative to dying in 1 year from properly treated cancer alongside suboptimally treated OUD (for a patient who wants cancer treatment)? </span></p><p dir="ltr" style="background-color: white; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">We want to know, </span><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; text-decoration-line: underline; text-decoration-skip-ink: none; vertical-align: baseline; white-space: pre-wrap;">where is the debate here</span><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">,</span><span style="background-color: transparent; font-size: 12pt; font-style: italic; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"> unless you don’t believe people who inject drugs are worthy of life-prolonging treatments? </span></p><p dir="ltr" style="background-color: white; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">This is why we think even asking the question this way is harmful to our patients and community, as it devalues the life of patients who live with a highly misunderstood and stigmatized disease (opioid use disorder). </span></p><p dir="ltr" style="background-color: white; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Additionally, the framing of the question as should he be offered chemotherapy “if he does not receive appropriate care” for his ongoing SUD suggests that we should all have a debate about whether we should make markedly life-prolonging therapies contingent on ‘compliance’ with SUD treatment. This is sort of akin to denying someone, say, oral surgery for tongue cancer because they still smoke. So, sure, that patient’s health will be better if they stop smoking, and their ongoing smoking may yet kill them, but also </span><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; text-decoration-line: underline; text-decoration-skip-ink: none; vertical-align: baseline; white-space: pre-wrap;">maybe it won’t</span><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">, and denying that patient a treatment (surgery) which will likely markedly prolong their life just because we don’t like the fact that another comorbidity is ‘uncontrolled’ is madness. We’d all urge that patient to stop smoking, offer them resources, keep the conversation going, while simultaneously giving them standard medical care. </span></p><p dir="ltr" style="background-color: white; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">We would certainly not pin their ability to get life-prolonging treatment on their ‘obedience’ to a treatment plan for their tobacco addiction, either. It’s only because addiction is so misunderstood and patients who use drugs are so stigmatized that we think this is an ok debate to even have. </span></p><p dir="ltr" style="background-color: white; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">In this context we submitted a letter to the editors of the AAHPM Quarterly asking for them to retract this discussion and to try to make amends for the harm we believe it causes our patients and community. (Of note, we really appreciate and are grateful for the perspective of the author advocating for giving chemotherapy for this patient while doing what you could do to help him with his SUD, but also thought the larger framing of the discussion was overall harmful and felt a retraction was best.) We are very disappointed they did not retract the article, and so we thought we would talk to our broader community about how we think about our patients who have SUD.</span></p><p dir="ltr" style="background-color: white; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Let’s start by taking a different approach to this story. </span></p><p dir="ltr" style="background-color: white; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Acknowledge people with SUD consistently experience barriers to appropriate care because of persistent healthcare stigma and inadequate understanding of addiction. Care of this population demands a close examination of our stereotypes of people who use drugs and become more aware of implicit and explicit biases.</span><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-size: 0.6em; vertical-align: super;">2</span></span></p><p dir="ltr" style="background-color: white; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Imagine if we did that--imagine what sort of debate and discussion we as a community could be having about our very ill patients who suffer from SUD alongside other serious illnesses? </span></p><p dir="ltr" style="background-color: white; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Just think about this very case - we could debate:</span></p><p dir="ltr" style="background-color: white; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;"></p><ul style="text-align: left;"><li><span style="background-color: transparent; font-size: 12pt; white-space: pre-wrap;">What *are* the best ways to support his safety while he gets chemo and lives with an active SUD?</span></li><li><span style="background-color: transparent; font-size: 12pt; white-space: pre-wrap;">If he also had severe pain from the cancer - is there a role for strong opioid agonists to treat that pain given his active SUD?</span></li><li><span style="background-color: transparent; font-size: 12pt; white-space: pre-wrap;">What is the role for palliative specialists in his care, vs addiction specialists and others?</span></li><li><span style="background-color: transparent; font-size: 12pt; white-space: pre-wrap;">What are the knowledge and skills palliative specialists should have to help patients in this situation?</span><span style="background-color: transparent; font-size: 12pt; white-space: pre-wrap;">And many more questions.</span></li></ul><p></p><p dir="ltr" style="background-color: white; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-size: 12pt; white-space: pre-wrap;">All of these questions are rooted in a perspective that views this patient’s life as precious and assumes that we health care professionals can and will lean into these most difficult of clinical scenarios with compassion and skill, and not give up on patients like the man in this case because there is challenge and risk.</span></p><p dir="ltr" style="background-color: white; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">There is more we can say, but we recommend that all of us in the palliative care community be prepared to promote evidence-based SUD care for patients with serious illness. Here are some basics:</span></p><p dir="ltr" style="background-color: white; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline;"><br /></span></p><p dir="ltr" style="background-color: white; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline;"></span><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"> 1. Treat addiction as a chronic disease and give it equal attention to other serious illnesses. A heroin overdose signals a period of increased disease activity requiring more robust healthcare support. Overdose is a significant exacerbation of disease and an opportunity for engaging the patient in life-saving treatment. People with SUD should be regularly offering life-saving therapies like buprenorphine or methadone for OUD.</span><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-size: 0.6em; vertical-align: super;">4</span></span></p><p dir="ltr" style="background-color: white; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"> 2. Engage in a goals and values discussion, including goals about substance use.“Not taking Suboxone and managing his heroin use on his own” is not a discussion. As PC clinicians, we must regularly probe further to understand the rationale behind patients’ decisions and help people grapple with ambivalence. In other disease states, when patients make decisions that we feel are not in their best interest, we explore these decisions in a non-judgmental fashion. We use communication techniques such as motivational interviewing and open-ended questions to stimulate a discussion that challenges the status quo and minimizes harm.</span><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-size: 0.6em; vertical-align: super;">5</span></span></p><p dir="ltr" style="background-color: white; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"> 3. Shared decision-making in a patient with SUD needs to incorporate discussing the benefits and tradeoffs of decisions and to provide information to help patients make choices that align with their goals. The patient’s interest in pursuing chemotherapy suggests an interest in life-prolonging treatment, which should not be undermined by a one-time decision not to engage in SUD treatment. Patients with SUD often require multiple engagements with different treatments before achieving remission.</span><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-size: 0.6em; vertical-align: super;">6 </span></span><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">We should never give up on patients with severe SUD, there is always hope, and there are </span><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; text-decoration-line: underline; text-decoration-skip-ink: none; vertical-align: baseline; white-space: pre-wrap;">always</span><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"> ways we can help them be suffer less, lead better lives, and be safer even if they continue to use harmful drugs or alcohol!</span></p><p dir="ltr" style="background-color: white; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"> 4. Attend to psychological trauma and provide trauma-informed care that recognizes that medical care (including a diagnosis of life-threatening illness and pursuing substance use disorder treatment) may be anxiety-producing, resulting in avoidance of medical care. </span><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-size: 0.6em; vertical-align: super;">7,8</span></span><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"> Identifying potential barriers to treatment and sources of suffering is core to providing both trauma-informed care and palliative care. As PC clinicians, we must respond with empathy and cultivate a safe environment. For addiction treatment at the first oncology visit, declining medication may not reflect long-term choices, and treatment should be reviewed at each encounter and integrated into standard practice.</span><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-size: 0.6em; vertical-align: super;">9</span></span><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"> Similarly, before confiscating the patient’s access to chemotherapy and deepening SUD disparities, a thorough differential for declining the Suboxone is needed. Did the patient have a prior experience with Suboxone for OUD, is Suboxone too expensive, would he instead engage in methadone maintenance treatment, is he worried Suboxone would not adequately treat underlying pain, etc.? Integrated treatment models that combine medication addiction treatment and life-saving treatment (see endocarditis literature!) have shown promising results.</span></p><p dir="ltr" style="background-color: white; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"> 5. Do not miss the opportunity for a discussion of harm reduction. </span><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-size: 0.6em; vertical-align: super;">10</span></span><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"> An opioid overdose represents a critical time to revisit goals and values. We should seek to understand what led to the overdose and consider preventing an overdose in the future such as offering naloxone, assessing current use and injection practices, and recommending never-use-alone resources. The National Harm Reduction Coalition website contains excellent information.</span><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-size: 0.6em; vertical-align: super;">11</span></span></p><p dir="ltr" style="background-color: white; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">In summary, while undoubtedly this patient’s ongoing heroin use will complicate his care, allowing him to die rapidly of his treatable (albeit not curable) cancer constitutes far more significant harm to him. As a field, rather than focus on whether people with SUD should receive care, we must examine existing policies, clinical practices, and stigma that create barriers for patients who use drugs to engage in treatment. Providing care to individuals with SUD and serious illness can be challenging, but it can also be some of the most rewarding professional work we do.</span></p><p dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;"><span style="font-family: Arial; font-size: 11pt; font-style: italic; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Katie Fitzgerald Jones MSN, APN (<a href="https://twitter.com/kfjonespallnp" target="_blank">@kfjonespallnp</a>) -- Hospice & Palliative Care Nurse Practitioner at VA Boston Healthcare System and Nursing Ph.D. student at Boston College.</span></p><p dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;"><span style="font-family: Arial; font-size: 11pt; font-style: italic; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Janet Ho, MPH, MD -- Palliative and Addiction Medicine Physician University of California San Francisco</span></p><p dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;"><span style="font-family: Arial; font-size: 11pt; font-style: italic; white-space: pre-wrap;">Zachary Sager (<a href="https://twitter.com/ZacharySagerMD" target="_blank">@ZacharySagerMD</a>), MD -- Psychiatrist and Hospice & Palliative Medicine Physician VA Boston Healthcare System</span></p><p dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;"><span style="font-family: Arial; font-size: 11pt; font-style: italic; white-space: pre-wrap;">Drew Rosielle (<a href="https://twitter.com/drosielle" target="_blank">@drosielle</a>), MD -- Palliative Medicine physician at the University of Minnesota Medical School/M Health Fairview </span></p><p dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;"><span style="font-family: Arial; font-size: 11pt; font-style: italic; white-space: pre-wrap;">Jessica Merlin (<a href="https://twitter.com/JessicaMerlinMD" target="_blank">@JessicaMerlinMD</a>), MD, Ph.D., MBA -- Addiction Medicine, Infectious Disease, and Palliative Medicine Physician University of Pittsburgh School of Medicine. </span></p><p dir="ltr" style="line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt; padding: 0pt 0pt 0pt 36pt; text-indent: -36pt;"><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">1.</span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span class="Apple-tab-span" style="white-space: pre;"> </span></span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Let's Think about it Again. </span><a href="http://aahpm.org/quarterly/winter-2-lets-think-about-it-again" style="text-decoration-line: none;" target="_blank"><span style="color: #1155cc; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; text-decoration-line: underline; text-decoration-skip-ink: none; vertical-align: baseline; white-space: pre-wrap;">http://aahpm.org/quarterly/winter-2-lets-think-about-it-again</span></a><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">. (Sorry, this is behind a paywall at AAHPM for members only.)</span></p><p dir="ltr" style="line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt; padding: 0pt 0pt 0pt 36pt; text-indent: -36pt;"><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">2.</span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span class="Apple-tab-span" style="white-space: pre;"> </span></span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Botticelli MP, Koh HK. Changing the Language of Addiction. </span><span style="color: #44546a; font-size: 12pt; font-style: italic; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">JAMA. </span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">2016;316(13):1361-1362.</span></p><p dir="ltr" style="line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt; padding: 0pt 0pt 0pt 36pt; text-indent: -36pt;"><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">3.</span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span class="Apple-tab-span" style="white-space: pre;"> </span></span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Ferrell BR, Twaddle ML, Melnick A, Meier DE. National Consensus Project Clinical Practice Guidelines for Quality Palliative Care Guidelines, 4th Edition. </span><span style="color: #44546a; font-size: 12pt; font-style: italic; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">J Palliat Med. </span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">2018.</span></p><p dir="ltr" style="line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt; padding: 0pt 0pt 0pt 36pt; text-indent: -36pt;"><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">4.</span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span class="Apple-tab-span" style="white-space: pre;"> </span></span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Larochelle MR, Bernstein R, Bernson D, et al. Touchpoints – Opportunities to predict and prevent opioid overdose: A cohort study. </span><span style="color: #44546a; font-size: 12pt; font-style: italic; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Drug and Alcohol Dependence. </span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">2019;204:107537.</span></p><p dir="ltr" style="line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt; padding: 0pt 0pt 0pt 36pt; text-indent: -36pt;"><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">5.</span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span class="Apple-tab-span" style="white-space: pre;"> </span></span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Shared Decision Making Tools. Substance Abuse and Mental Health Service Association Web site. </span><a href="https://www.samhsa.gov/brss-tacs/recovery-support-tools/shared-decision-making" style="text-decoration-line: none;"><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">https://www.samhsa.gov/brss-tacs/recovery-support-tools/shared-decision-making</span></a><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"> </span></p><p dir="ltr" style="line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt; padding: 0pt 0pt 0pt 36pt; text-indent: -36pt;"><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">6.</span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span class="Apple-tab-span" style="white-space: pre;"> </span></span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Snow RL, Simon RE, Jack HE, Oller D, Kehoe L, Wakeman SE. Patient experiences with a transitional, low-threshold clinic for the treatment of substance use disorder: A qualitative study of a bridge clinic. </span><span style="color: #44546a; font-size: 12pt; font-style: italic; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Journal of Substance Abuse Treatment. </span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">2019;107:1-7.</span></p><p dir="ltr" style="line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt; padding: 0pt 0pt 0pt 36pt; text-indent: -36pt;"><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">7.</span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span class="Apple-tab-span" style="white-space: pre;"> </span></span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Tripp JC, Jones JL, Back SE, Norman SB. Dealing With Complexity and Comorbidity: Comorbid PTSD and Substance Use Disorders. </span><span style="color: #44546a; font-size: 12pt; font-style: italic; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Current Treatment Options in Psychiatry. </span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">2019;6(3):188-197.</span></p><p dir="ltr" style="line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt; padding: 0pt 0pt 0pt 36pt; text-indent: -36pt;"><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">8.</span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span class="Apple-tab-span" style="white-space: pre;"> </span></span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Sager ZS, Wachen JS, Naik AD, Moye J. Post-Traumatic Stress Disorder Symptoms from Multiple Stressors Predict Chronic Pain in Cancer Survivors. </span><span style="color: #44546a; font-size: 12pt; font-style: italic; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Journal of Palliative Medicine. </span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">2020.</span></p><p dir="ltr" style="line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt; padding: 0pt 0pt 0pt 36pt; text-indent: -36pt;"><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">9.</span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span class="Apple-tab-span" style="white-space: pre;"> </span></span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Lagisetty P, Klasa K, Bush C, Heisler M, Chopra V, Bohnert A. Primary care models for treating opioid use disorders: What actually works? A systematic review. </span><span style="color: #44546a; font-size: 12pt; font-style: italic; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">PLoS One. </span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">2017;12(10):e0186315.</span></p><p dir="ltr" style="line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt; padding: 0pt 0pt 0pt 36pt; text-indent: -36pt;"><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">10.</span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span class="Apple-tab-span" style="white-space: pre;"> </span></span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Hawk M, Coulter RWS, Egan JE, et al. Harm reduction principles for healthcare settings. </span><span style="color: #44546a; font-size: 12pt; font-style: italic; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Harm Reduct J. </span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">2017;14(1):70.</span></p><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">11.</span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span class="Apple-tab-span" style="white-space: pre;"> </span></span><span style="color: #44546a; font-size: 12pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">National Harm Reduction Coalition Website http://harmreduction.org/</span></insert></div><insert here="" picture=""><div><insert here="" picture=""><br /></insert></div><br /></insert><meta name="twitter:card" content="summary" />
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<meta name="twitter:url" content="https://www.pallimed.org/2021/01/confronting-stigma-from-opioid-use.html" />Drew Rosielle MDhttp://www.blogger.com/profile/04345646798042773615noreply@blogger.comtag:blogger.com,1999:blog-13495125.post-42804187032200922492021-01-28T20:44:00.002-06:002021-04-07T11:47:47.438-05:00Fostering Student Interest in Palliative Care<div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEicFDv_jKMhSSNqQFj6N3e2CxjJtZr_3ngy-Y4Bd8mumZvmscZWg1cgiwE0LO_BaqsuPk3ZUzzg_knNsWQF949YfvrhiE5iAQRnJpuZ97Kqqrgxn4Z5QztCkCD_X_E2sj0pb_5OnQ/s1080/transdermal+fent+to+methadone+%25282%2529.png" style="display: block; padding: 1em 0; text-align: center; clear: right; float: right;"><img alt="" border="0" width="320" data-original-height="1080" data-original-width="1080" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEicFDv_jKMhSSNqQFj6N3e2CxjJtZr_3ngy-Y4Bd8mumZvmscZWg1cgiwE0LO_BaqsuPk3ZUzzg_knNsWQF949YfvrhiE5iAQRnJpuZ97Kqqrgxn4Z5QztCkCD_X_E2sj0pb_5OnQ/s320/transdermal+fent+to+methadone+%25282%2529.png"/></a></div>
by Christian Sinclair (<a href="https://twitter.com/ctsinclair" target="_blank">@ctsinclair</a>)
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Most palliative care teams love to have medical students on service, but the access may be variable. Some schools make palliative care rotations mandatory, some optional, while others make it hard to find or "build your own." I do outpatient palliative care, so I see medical students less often than my inpatient colleagues, but we do get a number of nursing students, pharmacy residents, psychology learners rotating with our clinic at the University of Kansas Medical Center. Having learners rotate is an excellent way to teach primary palliative care skills, to help learners early in their career on the best ways to introduce palliative care, and maybe finding a few future colleagues.<br><br>
So imagine my dismay on seeing this:
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<blockquote class="twitter-tweet"><p lang="en" dir="ltr">I *finally* get the courage to admit to people that I want to go into palliative care. People laugh and turn away. Or worse, “don’t worry you’ll change your mind!” <br><br>All my friends say they want to be surgeons. They get red carpets, egots, and champagne kisses!!<br><br>What gives?</p>— Sylvia Lane (@sylv_lane) <a href="https://twitter.com/sylv_lane/status/1353336916612149248?ref_src=twsrc%5Etfw">January 24, 2021</a></blockquote> <script async src="https://platform.twitter.com/widgets.js" charset="utf-8"></script>
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<i>(Editor note: <a href="about:invalid#zSoyz" target="_blank">Sylvia Lane wrote more about her decision to choose palliative care for a career here.</a>)</i>
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Or this tweet from from an AAHPM Poster Award winner:
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<blockquote class="twitter-tweet"><p lang="en" dir="ltr">Attending: "What specialty are you thinking of?"<br>Me: "<a href="https://twitter.com/hashtag/Palliative?src=hash&ref_src=twsrc%5Etfw">#Palliative</a>"<br>Attending: "No one has ever said that answer before."<br><br>Give me a couple years. I'm rounding up some troops! <a href="https://twitter.com/hashtag/hpm?src=hash&ref_src=twsrc%5Etfw">#hpm</a></p>— Kayla Sheehan, MD (@kksheehan) <a href="https://twitter.com/kksheehan/status/1021233008840339457?ref_src=twsrc%5Etfw">July 23, 2018</a></blockquote> <script async src="https://platform.twitter.com/widgets.js" charset="utf-8"></script>
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Take a few deep breaths. Those two learners are going to be OK. After sharing those potentially demoralizing experiences, the <a href="https://twitter.com/search?q=%23hapc&src=typeahead_click" target="_blank">#hapc (hospice and palliative care) Twitter community</a> lifted them up, sharing supportive stories, potential comebacks for the next time they hear something like that, resouces like joining AAHPM, and networking with other learners or local mentors. Some even shared their own challenging retorts to pusuing a career in hospice and palliative care.
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Are learners hearing this more often? What is the not-so-subtle message being conveyed about our work? What can we do to foster more interest in palliative care as a career and/or a skill set to build? What can we do about our colleagues who may be undermining great candidates for our field? I would love to hear your ideas. Because <a href="https://www.capc.org/blog/nourish-roots-importance-palliative-care-education-medical-school/" target="_blank">we need more people interested in working in palliative care and hospice as a career.</a> <i>(Editor's Note - that article was written for CAPC by one of the Twitter users above!)</i>
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If you are a learner who found this post, I am so glad you are interested. Here are some simple things for learners of all professions to get you started:<br><br>
- Find your local academic palliative care faculty or academic hospice organization <br><br>
- If you are on Twitter follow hashtags like <a href="https://twitter.com/search?q=%23hapc&src=typeahead_click" target="_blank">#hapc</a> or <a href="https://twitter.com/search?q=%23palliativecare&src=typed_query" target="_blank">#palliativecare</a>, and <a href="https://twitter.com/i/lists/1354969720156528640" target="_blank">check out this list of some of the first people and orgs to follow in palliative care</a> <br><br>
- If you cannot find someone in your specialty, start with someone doing palliative care work in another specialty as a resource<br><br>
- Find the national organization that represents your field and either does palliative care and hospice work or has a special interest group:<br><br>
- - <a href="https://aahpm.org/" target="_blank">American Academy of Hospice and Palliative Medicine (AAHPM)</a> - <a href="https://aahpm.org/" target="_blank">www.aahpm.org</a><br><br>
- - <a href="https://advancingexpertcare.org/" target="_blank">Hospice and Palliative Nurses Association (HPNA)</a> - <a href="https://advancingexpertcare.org/" target="_blank">www.advancingexpertcare.org</a><br><br>
- - <a href="https://pahpm.org/" target="_blank">Physician Assistants in Hospice and Palliative Medicine (PAHPM)</a> - <a href="https://pahpm.org/" target="_blank">www.pahpm.org</a><br><br>
- - <a href="https://www.swhpn.org/" target="_blank">Social Work Hospice and Palliative Care Network (SWHPN)</a> - <a href="https://www.swhpn.org/" target="_blank">www.swhpn.org</a><br><br>
- - <a href="https://www.palliativepharmacist.org/" target="_blank">Society of Pain and Palliative Care Pharmacists</a> - <a href="https://www.palliativepharmacist.org/" target="_blank">www.palliativepharmacist.org</a>
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If you have some great ideas, please share them in comments below or share them with me on Twitter and I will add them to the original post.
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*Both people gave permission to embed their posts here.
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For more <a href="https://www.pallimed.org/search/label/learners">Pallimed posts about learners.</a><br />
For more <a href="https://www.pallimed.org/search/label/sinclair">Pallimed posts by Dr. Sinclair click here.</a>
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<i>Christian Sinclair, MD, FAAHPM, is a associate professor of palliative medicine at the Univeristy of Kansas Health System. He is editor-in-chief of Pallimed, and cannot wait to play board games in person again.</i>
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<meta name="twitter:url" content="https://www.pallimed.org/2021/01/fostering-student-interest-in.html" />Christian Sinclairhttp://www.blogger.com/profile/14685043408496367587noreply@blogger.com