I applaud Dr. Kertesz’ analysis of the aforementioned psychiatry article highlighting the disparity between the conclusion of the abstract stating these results are limited by their ecology and statements made in the article attesting to the possible benefit of decreased suicides by tapering opioids. As Dr. Kertez suggests the author’s assumptions of the cause-and-effect relationship between dose tapering and suicide needs more research. They may be as Dr. Kertesz alludes variables that co-exist due to other conditions such as economic status of a community. Dr. Kertesz’ rightly points out the relationship between tapering of opioids and suicide is complex. Qualitative stories can be found in the press about patients committing suicide when their opioids are tapered. Other articles https://pubmed.ncbi.nlm.nih.gov/36454732/ also indicate that tapering of opioids can increase suicide risk in some patients. Thanks to Dr. Kertesz for providing his analysis of the risky conclusions made by the authors given other data arguing to the contrary.
Why is it that A) there’s seemingly only ONE “expert” who dominates the narrative about this and we never have an expert speaking equally about patients who BENEFIT from LTOT? And B) I continually see research and conclusions drawn on this topic that are correlative but not causative being used interchangeably? Not here though, thank you Dr. Kertesz for reminding everyone to be objective and use the data AND personalized treatment for individual patients. Great job!
As a followup to Dr Kertesz' intelligent analysis, I suggest reading a landmark paper by Larry Aubrey and B Thomas Carr, in "Frontiers in Pain Research". titled "Overdose, opioid treatment admissions and prescription opioid pain reliever relationships: United States, 2010–2019". [Front. Pain Res., 04 August 2022
This paper demonstrates that there is no correlation between state-level rates of opioid prescribing versus rates of hospitalization for opioid toxicity or rates of opioid-overdose-involved mortality. And there has been no such relationship since at least as far back as 2012.
This outcome surely must have been evident to the writers of the US CDC and Veterans Administration opioid prescribing guidelines in 2016, and of revisions published in November 2022. But CDC continues to proclaim that over-prescribing by clinicians has been a major driver in a so-called "prescription opioid crisis". Such assertions are at best in error; at worst we may reasonably surmise that CDC is wedded to a politically dictated agenda that is harming millions of chronic pain patients despite its lack of scientific basis.
Thanks for reviewing this study for the rest of us. To me, a retired pediatric pulmonologist, the idea that a single change in physician prescription practice would have a measurable impact on societal suicide incidence is absurdly simplistic and naive. There are so many factors, including the impact of the recent pandemic, the political turmoil of our time, the divisions surrounding our adolescent and young adult population, and the decreasing attendance in formal religious settings are just some of the multitude of factors that might contribute to suicide. I hope that the journal included an editorial which urged the readers to maintain a healthy skepticism of this study and others.
You undoubtedly observe numerous confounding factors in any such simplistic study, Doctor.
Add a bit of motivated reasoning and what might have been a useful conversation becomes complete and utter nonsense.
"Associations" can be no more than a signal inviting further study. We live in a time where all correlation equals causation. It was ever thus for everyday folks fully occupied with their struggle to survive and thrive, but it has now become acceptable and even desirable amongst those who are being paid to know better.
Perhaps that is, in and of itself, a signal; that we may not be paying people to do what we thought we were paying them for.
One of the themes of my work is that I'm frustrated with any party that seeks to sell the "easy answer". And in medicine, it's often the practicing docs or the research docs who look for easy answers to provide. Often the answers are not easy. The work of dealing with complex or uncertain signals isn't bad work. I'm still a bit surprised by how many doctors (and, at times, journalists) just run away from that work.
"... in medicine, it's often the practicing docs or the research docs who look for easy answers to provide. Often the answers are not easy. The work of dealing with complex or uncertain signals isn't bad work. I'm still a bit surprised by how many doctors (and, at times, journalists) just run away from that work."
The unfortunately sad and discouraging truth is that you, Dr. Kertesz, are of an extremely rare conscientious and caring quality, recognizing your oath and mission as a genuine healer and advocate of individuals - whereas it seems that the vast majority of physicians are literally and figuratively "running for the exits" in all manners where it comes to issues surrounding patient "quality of life". It seems truly "all about them" (and their "fame and fortunes"), and not about the fellow humans that such charlatans have pledged to serve.
This is yet another example of “so-called experts” (tone of derision entirely intended) (in this case, the AJP article authors) making recommendations in the absence of strong or conclusive data.
This is not to say that we should be nihilists, or to not make therapeutic decisions in the absence of strong evidence...we do this in many scenarios, daily (I’d go as far as to say that the majority of clinical scenarios require decisions in the absence of solid evidence). But while such decisions, made with the culmination of imperfect evidence, clinical experience, biologic plausibility, and patient preference, are necessary, they have no place in any guideline/cookbook style recommendation. Yes, one can do things a certain way, cuz your patient needs some guidance/advice/action. But in the absence of evidence, that “way” should not be presumed to be the only way, or even the “right” way.
Much more humility is required of experts...in all fields....when they are speaking from opinion rather than bringing the evidence. You’d think at least that much has been learned from the pandemic. But sadly, that does not seem to be the case.
Thanks as always, for your posts. For Canadians, I’m hoping to spread the word about proposed changes to the Canada Food and Drug Act. I just watched an urgent message from Paediatrician Dr. Susan Natsheh which was highlighted on Dr. Jessica Rose’s Substack. Deadline for action is tomorrow, April 26th, 2023. Please watch Dr. Natsheh’s message and consider responding as outlined in the video. Thanks for reading this. It’s time to pull together as much and act as we can! https://brightlightnews.com/doctors-urgent-message-to-canadians/
It is now blatantly clear that big pharma and medicine make most decisions based on nothing more than their desire to control us and make profits. Data has very little to do with those drugs you are taking and the lack of health care you are receiving. Drugs are now involved in more murders than any other cause of death.
Isn't this article an example of how committing the Ecological Fallacy can mislead no matter how carefully population-level outcomes have been tallied and massaged ?
Yes it is. What was so weird is that the paper opaquely acknowledged ecological fallacy as a real thing, and then kind of positioned itself rhetorically to make the arguments about individual care anyway. I also tried to offer some hint of why the population-level outcomes might not be entirely trustworthy. Those population-level outcomes depend on statistical models. The core assumptions of those models were not ones I found entirely compelling and I felt there should have been data provided to the readers and peer reviewers to make those assumptions plausible.
Having had association with many people in the criminal court system who committed usually theft offenses following a decrease in prescribed opiates, it makes sense to me that suicide numbers would increase 1-2 years after the decrease. People can obtain opiates on the street without much trouble initially, until a spouse or parent starts confronting about the pawned items taken from the house, or until the addicted party loses a job, or gives a car to a drug dealer, or leaves the children alone to meet with the dealer and the spouse becomes aware of this. Often the losses occur over time, as do the increases in depression and desperation. As far as people with a history of addiction, you are right that doctors need to know their patients, but you are also aware that the patients' friends and relatives are often ignored when they plead with hospital staff to avoid the opiates, which start the spiral from sobriety back to whatever possessed their lives prior to a surgery or injury.
Ruth, I see the "other side of the street". I've read social media postings of thousands of non-criminal chronic pain patients who can no longer get safe and effective opioid therapy because public policy is based on observations primarily of criminal populations.
US DEA has terrorized and driven thousands of clinicians out of pain medicine by operating without effective oversight, confiscating clinicians assets long before trial, prominently announcing investigations with the intention of ruining the doctor's practice and denying them resources for their own defense, and coercing employees to testify against their employers in exchange for not being prosecuted. US DEA can aptly be characterized as a racketeer influenced and corrupt organization.
I must also challenge a popular meme: it is rare for young people to lapse into addiction after being treated by a doctor with opioid pain relievers. Youth under age 19 have the lowest opioid prescription rates of any population cohort, and seniors over age 62 have the highest. But young adults age 24-34 have drug overdose mortality rates three times higher than seniors -- and those mortalities stem almost entirely from illegal street drugs, primarily imported Fentanyl.
I felt the need to mention here that there is a difference between dependence and addiction, and while all people on long term opioid therapy become dependent they are not necessarily addicted. Forced dose reductions or discontinuation in patients on chronic opioid therapy that result in them turning to the streets for illicit opioids sounds like a provider-assisted transition from dependence to addiction.
Families pleading with hospital staff to avoid opioids doesn’t take into account the patient’s autonomy - unless an adult patient is incapacitated or without decision-making capacity they get to make their own decisions in conjunction with their healthcare team. And as someone who worked in the hospital setting for a decade and administered many opioids, I can definitely say that my experience was that patients with a history of opioid abuse usually had a harder time getting those meds prescribed than patients without that history.
You must have been at a good hospital. Patients with a history of street drug addiction, who are sober at the time of a medical injury/surgery, often are very pain avoidant, moreso than many of us, as you probably know, and won't report their history to providers. I've witnessed providers believing they were honoring their patients' autonomy and ignoring the pleading of wives and friends (and sometimes professionals with knowledge of the history), rather than making an effort to meet with the patient and concerned parties to discuss the reasons for the concerns and determine a safer response. One man I dealt with had a successful business, beautiful family with three young daughters, multiple employees, lost all of that and ended up in prison within three years of a surgery. Of course opioids work well for some people ongoing, but if the possible devastation is taken into account, the prescribing would have to include a much more comprehensive process. In just the one example I note, there were four lives horribly affected, others out of work, and who knows how many others related to that person. And he's only one of millions.
Evaluation is critical to see the differences in patients.
You have highlighted a critical difference also in mentioning surgery and injuries. Those usually do improve. People with incurable and progressive conditions do not. There aren’t people with such conditions who are pain free. They just need enough treatment to function. And they have the same cascade of people depending on them/around them.
Like a dancing bear the wonder isnt the degree of elegant dancing but that it dances at all. Its not surprising that politically motivated studies have little useful data, ots that they have any data at all.
Same way with politically motivated reporting and that that is the only type of reporting that we have from "reporters"
I am going to share this article with my GP. I started seeing them (private practice) after the hospital affiliated clinic I had been at for years suddenly tried to taper my opioids, this change was introduced to me by a doctor who had never seen me as a patient before and who had not exchanged more than 10 words with me. She mumbled something and handled me a pamphlet. She also incorrectly calculated my daily morphine equivalence and when I corrected her she told je I was wrong (I am not as my dose is under the amount stated in tbe suggested government opioid guidelines)I have several serious incurable conditions that cause severe chronic pain that affects my daily ability to function normally. Opioids have without a doubt improved my functioning and quality of life with almost zero side effects. I have NOT needed ever increasing doses and have been on the same dose for many years. On the other hand every supposedly safer “opioid alternative” that has been given to me has caused me significant & sometimes serious side effects and also not improved my pain & functioning.
We long term users are faced with the ying/yang of abusers. I've not yet faced my pain manager suggesting any changes because I am being treated as a person not a statistic. I am well below the daily equivalent and titrate my dosage by cutting pills which helps avoid spikes in relief. I have needed slightly more over time but that corresponds to aging which my doctor and I assess. I find it's all about trying to find a balance that must take into consideration the individual. We both understand the nonsense of regulators noting that they simply add costs with little benefit, all in an effort to be "doing something".
Your clinic must have been alerted by authorities to some situation and in response, clinicians were directed to "do something". "She mumbled something and handled me a pamphlet." - You couldn't hear her because there was no relationship, just following the script. I often dread any change in providers and less well informed replacements who can't be bothered to check the patient chart. Tragic failure.
Pain has always been known to be a subjective experience. But there are objective observations we clinicians can utilize to inform ourselves so we provide the appropriate care for our patients. Years of experience with hundreds of patients have shown me the difference of whom to worry about and whom not. It frosts me to hear stories like yours wherein a clinician would willy-nilly evaluate for you and, no less, on the basis of polices set by inexpert or uneducated committees instead of experience and actual data. I hope you are and remain able to determine your best care in collaboration with the clinician you trust.
If this is true:
Poor Diet -> Poor Health -> Cancer, CVD
Then maybe this is, too:
Poor Diet -> Poor Mental Health -> Suicides, Drugs, Gun Deaths
I applaud Dr. Kertesz’ analysis of the aforementioned psychiatry article highlighting the disparity between the conclusion of the abstract stating these results are limited by their ecology and statements made in the article attesting to the possible benefit of decreased suicides by tapering opioids. As Dr. Kertez suggests the author’s assumptions of the cause-and-effect relationship between dose tapering and suicide needs more research. They may be as Dr. Kertesz alludes variables that co-exist due to other conditions such as economic status of a community. Dr. Kertesz’ rightly points out the relationship between tapering of opioids and suicide is complex. Qualitative stories can be found in the press about patients committing suicide when their opioids are tapered. Other articles https://pubmed.ncbi.nlm.nih.gov/36454732/ also indicate that tapering of opioids can increase suicide risk in some patients. Thanks to Dr. Kertesz for providing his analysis of the risky conclusions made by the authors given other data arguing to the contrary.
Why is it that A) there’s seemingly only ONE “expert” who dominates the narrative about this and we never have an expert speaking equally about patients who BENEFIT from LTOT? And B) I continually see research and conclusions drawn on this topic that are correlative but not causative being used interchangeably? Not here though, thank you Dr. Kertesz for reminding everyone to be objective and use the data AND personalized treatment for individual patients. Great job!
As a followup to Dr Kertesz' intelligent analysis, I suggest reading a landmark paper by Larry Aubrey and B Thomas Carr, in "Frontiers in Pain Research". titled "Overdose, opioid treatment admissions and prescription opioid pain reliever relationships: United States, 2010–2019". [Front. Pain Res., 04 August 2022
Sec. Pain Research Methods
Volume 3 - 2022 | https://doi.org/10.3389/fpain.2022.884674]
This paper demonstrates that there is no correlation between state-level rates of opioid prescribing versus rates of hospitalization for opioid toxicity or rates of opioid-overdose-involved mortality. And there has been no such relationship since at least as far back as 2012.
This outcome surely must have been evident to the writers of the US CDC and Veterans Administration opioid prescribing guidelines in 2016, and of revisions published in November 2022. But CDC continues to proclaim that over-prescribing by clinicians has been a major driver in a so-called "prescription opioid crisis". Such assertions are at best in error; at worst we may reasonably surmise that CDC is wedded to a politically dictated agenda that is harming millions of chronic pain patients despite its lack of scientific basis.
Thanks for reviewing this study for the rest of us. To me, a retired pediatric pulmonologist, the idea that a single change in physician prescription practice would have a measurable impact on societal suicide incidence is absurdly simplistic and naive. There are so many factors, including the impact of the recent pandemic, the political turmoil of our time, the divisions surrounding our adolescent and young adult population, and the decreasing attendance in formal religious settings are just some of the multitude of factors that might contribute to suicide. I hope that the journal included an editorial which urged the readers to maintain a healthy skepticism of this study and others.
You undoubtedly observe numerous confounding factors in any such simplistic study, Doctor.
Add a bit of motivated reasoning and what might have been a useful conversation becomes complete and utter nonsense.
"Associations" can be no more than a signal inviting further study. We live in a time where all correlation equals causation. It was ever thus for everyday folks fully occupied with their struggle to survive and thrive, but it has now become acceptable and even desirable amongst those who are being paid to know better.
Perhaps that is, in and of itself, a signal; that we may not be paying people to do what we thought we were paying them for.
One of the themes of my work is that I'm frustrated with any party that seeks to sell the "easy answer". And in medicine, it's often the practicing docs or the research docs who look for easy answers to provide. Often the answers are not easy. The work of dealing with complex or uncertain signals isn't bad work. I'm still a bit surprised by how many doctors (and, at times, journalists) just run away from that work.
"... in medicine, it's often the practicing docs or the research docs who look for easy answers to provide. Often the answers are not easy. The work of dealing with complex or uncertain signals isn't bad work. I'm still a bit surprised by how many doctors (and, at times, journalists) just run away from that work."
The unfortunately sad and discouraging truth is that you, Dr. Kertesz, are of an extremely rare conscientious and caring quality, recognizing your oath and mission as a genuine healer and advocate of individuals - whereas it seems that the vast majority of physicians are literally and figuratively "running for the exits" in all manners where it comes to issues surrounding patient "quality of life". It seems truly "all about them" (and their "fame and fortunes"), and not about the fellow humans that such charlatans have pledged to serve.
This is yet another example of “so-called experts” (tone of derision entirely intended) (in this case, the AJP article authors) making recommendations in the absence of strong or conclusive data.
This is not to say that we should be nihilists, or to not make therapeutic decisions in the absence of strong evidence...we do this in many scenarios, daily (I’d go as far as to say that the majority of clinical scenarios require decisions in the absence of solid evidence). But while such decisions, made with the culmination of imperfect evidence, clinical experience, biologic plausibility, and patient preference, are necessary, they have no place in any guideline/cookbook style recommendation. Yes, one can do things a certain way, cuz your patient needs some guidance/advice/action. But in the absence of evidence, that “way” should not be presumed to be the only way, or even the “right” way.
Much more humility is required of experts...in all fields....when they are speaking from opinion rather than bringing the evidence. You’d think at least that much has been learned from the pandemic. But sadly, that does not seem to be the case.
Thanks as always, for your posts. For Canadians, I’m hoping to spread the word about proposed changes to the Canada Food and Drug Act. I just watched an urgent message from Paediatrician Dr. Susan Natsheh which was highlighted on Dr. Jessica Rose’s Substack. Deadline for action is tomorrow, April 26th, 2023. Please watch Dr. Natsheh’s message and consider responding as outlined in the video. Thanks for reading this. It’s time to pull together as much and act as we can! https://brightlightnews.com/doctors-urgent-message-to-canadians/
It is now blatantly clear that big pharma and medicine make most decisions based on nothing more than their desire to control us and make profits. Data has very little to do with those drugs you are taking and the lack of health care you are receiving. Drugs are now involved in more murders than any other cause of death.
Isn't this article an example of how committing the Ecological Fallacy can mislead no matter how carefully population-level outcomes have been tallied and massaged ?
Yes it is. What was so weird is that the paper opaquely acknowledged ecological fallacy as a real thing, and then kind of positioned itself rhetorically to make the arguments about individual care anyway. I also tried to offer some hint of why the population-level outcomes might not be entirely trustworthy. Those population-level outcomes depend on statistical models. The core assumptions of those models were not ones I found entirely compelling and I felt there should have been data provided to the readers and peer reviewers to make those assumptions plausible.
Having had association with many people in the criminal court system who committed usually theft offenses following a decrease in prescribed opiates, it makes sense to me that suicide numbers would increase 1-2 years after the decrease. People can obtain opiates on the street without much trouble initially, until a spouse or parent starts confronting about the pawned items taken from the house, or until the addicted party loses a job, or gives a car to a drug dealer, or leaves the children alone to meet with the dealer and the spouse becomes aware of this. Often the losses occur over time, as do the increases in depression and desperation. As far as people with a history of addiction, you are right that doctors need to know their patients, but you are also aware that the patients' friends and relatives are often ignored when they plead with hospital staff to avoid the opiates, which start the spiral from sobriety back to whatever possessed their lives prior to a surgery or injury.
Ruth, I see the "other side of the street". I've read social media postings of thousands of non-criminal chronic pain patients who can no longer get safe and effective opioid therapy because public policy is based on observations primarily of criminal populations.
US DEA has terrorized and driven thousands of clinicians out of pain medicine by operating without effective oversight, confiscating clinicians assets long before trial, prominently announcing investigations with the intention of ruining the doctor's practice and denying them resources for their own defense, and coercing employees to testify against their employers in exchange for not being prosecuted. US DEA can aptly be characterized as a racketeer influenced and corrupt organization.
I must also challenge a popular meme: it is rare for young people to lapse into addiction after being treated by a doctor with opioid pain relievers. Youth under age 19 have the lowest opioid prescription rates of any population cohort, and seniors over age 62 have the highest. But young adults age 24-34 have drug overdose mortality rates three times higher than seniors -- and those mortalities stem almost entirely from illegal street drugs, primarily imported Fentanyl.
I felt the need to mention here that there is a difference between dependence and addiction, and while all people on long term opioid therapy become dependent they are not necessarily addicted. Forced dose reductions or discontinuation in patients on chronic opioid therapy that result in them turning to the streets for illicit opioids sounds like a provider-assisted transition from dependence to addiction.
Families pleading with hospital staff to avoid opioids doesn’t take into account the patient’s autonomy - unless an adult patient is incapacitated or without decision-making capacity they get to make their own decisions in conjunction with their healthcare team. And as someone who worked in the hospital setting for a decade and administered many opioids, I can definitely say that my experience was that patients with a history of opioid abuse usually had a harder time getting those meds prescribed than patients without that history.
You must have been at a good hospital. Patients with a history of street drug addiction, who are sober at the time of a medical injury/surgery, often are very pain avoidant, moreso than many of us, as you probably know, and won't report their history to providers. I've witnessed providers believing they were honoring their patients' autonomy and ignoring the pleading of wives and friends (and sometimes professionals with knowledge of the history), rather than making an effort to meet with the patient and concerned parties to discuss the reasons for the concerns and determine a safer response. One man I dealt with had a successful business, beautiful family with three young daughters, multiple employees, lost all of that and ended up in prison within three years of a surgery. Of course opioids work well for some people ongoing, but if the possible devastation is taken into account, the prescribing would have to include a much more comprehensive process. In just the one example I note, there were four lives horribly affected, others out of work, and who knows how many others related to that person. And he's only one of millions.
Evaluation is critical to see the differences in patients.
You have highlighted a critical difference also in mentioning surgery and injuries. Those usually do improve. People with incurable and progressive conditions do not. There aren’t people with such conditions who are pain free. They just need enough treatment to function. And they have the same cascade of people depending on them/around them.
Like a dancing bear the wonder isnt the degree of elegant dancing but that it dances at all. Its not surprising that politically motivated studies have little useful data, ots that they have any data at all.
Same way with politically motivated reporting and that that is the only type of reporting that we have from "reporters"
Politics ruin everything
I am going to share this article with my GP. I started seeing them (private practice) after the hospital affiliated clinic I had been at for years suddenly tried to taper my opioids, this change was introduced to me by a doctor who had never seen me as a patient before and who had not exchanged more than 10 words with me. She mumbled something and handled me a pamphlet. She also incorrectly calculated my daily morphine equivalence and when I corrected her she told je I was wrong (I am not as my dose is under the amount stated in tbe suggested government opioid guidelines)I have several serious incurable conditions that cause severe chronic pain that affects my daily ability to function normally. Opioids have without a doubt improved my functioning and quality of life with almost zero side effects. I have NOT needed ever increasing doses and have been on the same dose for many years. On the other hand every supposedly safer “opioid alternative” that has been given to me has caused me significant & sometimes serious side effects and also not improved my pain & functioning.
We long term users are faced with the ying/yang of abusers. I've not yet faced my pain manager suggesting any changes because I am being treated as a person not a statistic. I am well below the daily equivalent and titrate my dosage by cutting pills which helps avoid spikes in relief. I have needed slightly more over time but that corresponds to aging which my doctor and I assess. I find it's all about trying to find a balance that must take into consideration the individual. We both understand the nonsense of regulators noting that they simply add costs with little benefit, all in an effort to be "doing something".
Your clinic must have been alerted by authorities to some situation and in response, clinicians were directed to "do something". "She mumbled something and handled me a pamphlet." - You couldn't hear her because there was no relationship, just following the script. I often dread any change in providers and less well informed replacements who can't be bothered to check the patient chart. Tragic failure.
Pain has always been known to be a subjective experience. But there are objective observations we clinicians can utilize to inform ourselves so we provide the appropriate care for our patients. Years of experience with hundreds of patients have shown me the difference of whom to worry about and whom not. It frosts me to hear stories like yours wherein a clinician would willy-nilly evaluate for you and, no less, on the basis of polices set by inexpert or uneducated committees instead of experience and actual data. I hope you are and remain able to determine your best care in collaboration with the clinician you trust.